Pro Tips for Best EHS Audits (Part 3): EHS Audit Follow-up

Posted on November 20, 2023 by Kevin Lehner

The purpose of an EHS audit follow-up is to check that EHS risk, including risk of noncompliance, is managed to a level that the organization considers acceptable. Noncompliance with applicable government laws and other requirements are examples of EHS risk sources that need to be controlled. An EHS audit checks that risk controls are in place and effective. Risk controls can be engineering controls like air pollution control devices, administrative controls like training and work instructions and others.

EHS Audit Findings

The results of an audit are called findings. These can either be positive findings that the controls are in place and effective, or negative. Negative findings are nonconformance’s. Positive findings are good news but not something the organization needs to act on. Positive findings confirm that “what should be is” and that “what should not be is not.

Negative findings however are actionable and create opportunities to improve EHS performance. In Part 2 of this EHS Compliance Audit series, we discussed how negative findings are written and communicated verbally at the end of the audit. As a follow-up to the active evidence gathering and verbal reporting, a written report should be prepared and distributed to document the results of the audit.

Preparing the EHS Audit Follow-Up Report

The audit report presents the results to the auditee and others and helps an organization gauge EHS performance. The report should be concise and to the point and the tone of the report should be factual and nonjudgmental.

A key part of the EHS audit follow-up report are the negative findings that were made during the audit. The EHS audit follow-up report formalizes the findings in a way that the auditee can act on them. The reported negative findings need to include enough information so that they can be investigated and ultimately fixed in a way that they do not happen again.

Here is an example outline for an EHS audit follow-up report.

Executive Summary
Background Purpose and Scope
Findings
Conclusions
Recommendations
Discussion
Appendices

Correction and Corrective Action

Negative EHS audit findings point to EHS risks that need to be better controlled. They are the result of a potential noncompliance with a legal requirement or discovery of some other issue. If left uncorrected they can increase risk and lead to enhanced legal action by a regulatory agency (knowing and willful violation). To avoid exposure to these enhanced penalties, it is important that organizations have a good corrective action process in place.

There are 5 steps in an effective corrective action processes.

Short Term Correction
Investigate the Cause
Identify a Corrective Action
Implement the Corrective Action
Verify the Corrective Action is Effective

The following is a brief description of these steps.

Short Term Correction

Findings that identify a potential serious risk need to be addressed as soon as possible. Continuing to operate equipment that exposes workers to injury after a finding is made is bad business. If a worker were to become injured after the nonconformance was reported the penalties and fines could escalate dramatically. A correction to quickly reduce the risk from the nonconformance needs to be put in place as soon as practical.

Investigate THE Cause

Once the correction has been put in place a corrective action plan needs to be established. Responsibility to investigate the cause of an audit finding should be assigned to someone with knowledge of and experience with the corrective action process. This knowledge and experience will help identify the root cause of the finding. Once the root cause is established an appropriate corrective action can be proposed that prevents the problem from recurring in the future.

Knowledge and use of root cause analysis tools like “5 Why Cause Analysis” ensure the cause of the unacceptable risk level is identified. Here is an example a “5 Why Cause Analysis”.

This example is for an incident that happened at a roll calendar for polishing extruded plastics sheets. An employee was caught in an in running nip between the rolls and luckily only sustained a recordable injury. This incident could have easily been an amputation or a fatality.

Why?	Answer
Why was the OHS hazard of being caught in the nip on the calendar not addressed?	The machine was new, and no one thought to do a Job Safety Analysis (JSA) before it was installed and operated.
Why did no one perform a JSA?	Performing a JSA to review potential OHS hazards and risk are not part of the capital investment approval process.
Why was OHS hazard and risk review not part of the capital investment process?	The manager of the extrusion department manager did not know that a JSA hazard and risk review should be undertaken for all new equipment as part of the purchase process.
Why was extrusion department manager unaware of the need to review hazards and risks for new equipment?	An existing employee had recently been promoted to manager of the extrusion department and they had not been informed of the requirement.
Why had the new extrusion department manager not been informed?	Our organization has not established a process to identify training needs and provide training to employees when they transfer to a new position within the company.

Table 1 – Example 5 why analysis

Identify a Corrective Action

Once the cause is established, a suitable corrective action can be identified to reduce the risk to an acceptable level. The effort needed to identify a suitable corrective action is proportional to the finding risk level. The higher the risk, the more effort needed to figure out the best way to address it. A finding that an emergency evacuation map could be hidden behind a door when it is opened, is much easier to correct than the finding of an ineffective control to treat wastewater discharge to a municipal sanitary sewer.

The cause analysis process should have an approval step to confirm the cause analysis was performed with skill and that the corrective action is aligned with the identified cause of the finding. This review and approval can be done by the auditor who made the finding or others in the organization who can impartially review the cause and proposed corrective action.

If the cause and/or the proposed corrective action are found to be deficient during the review, the assignees should be consulted and asked to rethink the cause analysis and corrective action. The evaluation and approval of potential corrective actions requires striking a balance between risk and opportunity. It is not possible to reduce all risk levels to zero.

Some processes have hazards with risk that are difficult to control and the organization needs to think carefully about what level of risk it is willing to accept. In running nips on plastic extrusion rollers is a good example. It is very difficult to properly guard an in running nip on these machines. The guard would prevent the process from working properly.

As a result, the corrective action cannot be the elimination of the hazard or installation of a physical guard (engineering control). Instead, there may need to be several independent controls such as installing a rope e-stop, providing training to employees on how to operate the process safely and even evaluating the operators competence to ensure they understand the hazard and the associated risk.

Once both the cause and the corrective action(s) are approved the assignee should be authorized to implement the corrective action.

Implement the Corrective Action

The implementation of the chosen corrective action may take days, weeks or even months depending on what needs to be done. Moving an emergency evacuation sign to a better location can be done almost immediately while designing and installing an upgraded wastewater treatment process may take many months.

Verify the Corrective Action is Effective

Verification that the corrective action has been implemented and that it is effective is the last step in the process. It confirms that the problem causing risk, has reduced that risk. The verification can be done upon completion of the corrective action or during the next audit. When the corrective action is verified, it can be closed.

Tracking EHS Audit Corrective Action Progress

Historically, keeping track of progress toward completing corrective action was done with paper forms that went from in-basket to in-basket. Once complete they were placed in a file drawer for storage. Later, electronic methods including excel spreadsheets and other types of electronic documents were used with some success. However, these tracking methods require much effort and often lead to miscommunications or missed deadlines of incomplete corrective actions for findings. The result was the corrective action process was not successful in reducing risk in a timely fashion and increased risk to the organization.

Within the last few years cloud-based applications have emerged that solved many of the problems with paper or spreadsheet corrective action tracking systems. These applications allow quick access to users and are readily accessible almost anywhere.

Modern corrective action application — Figure 1 – Modern Corrective Action Application

Cloud based database applications help organizations quickly find the status of any CA and drill down to details for each CA.

Figure 2 – Drill Down Corrective Actions Detail

Applications like CorrectTrack establish users permissions to view, change, verify and approve corrective actions. A permissions based peer review process also helps ensure that corrective actions are investigated thoroughly and verified before they are closed.

Other advantages of a cloud based app like CorrectTrack are:

Notify persons of status changes of a CA
Define a standard process for doing CA
At a glance dashboards for users
Provide notifications when CAs are coming due, or past due
Provide a record of who changed what, when and why
User permissions allow visibility of the CA system to leadership

Conclusion

Effective corrective action processes are powerful tools that help organizations improve EHS performance over time. Investing in, and continually improving the corrective action process will provide a significant short term and long term return.

This EHS Audit Follow-up post is part 3 of a three part article on EHS Auditing. Part 1 and 2 discussed how to plan an EHS audit and conduct an EHS audit. This concludes our three-part series on EHS audits.

We welcome and encourage feedback on this series. Contact us directly at kalehner@envcompsys.com and 262-949-2965, or visit us online for more information: ECSI or CorrectTrack.

Pro-Tips for Best EHS Audits (Part 2): Conducting an EHS Compliance Audit

Posted on August 31, 2023 by Kevin Lehner

Compliance audits confirm an organization’s compliance status with environmental and occupational health and safety regulations. Audits also help manage risk of violations and fines. Customers, boards of directors and others care about EHS regulatory compliance and use audit results to make important business decisions. EHS audits will become even more important in the future as more organizations seek independent verification of their EHS and ESG performance.

Opening Meeting

An EHS compliance audit can be intimidating for an organization. Conducting an opening meeting helps to:

Explain the purpose, scope, and objective(s) of the audit.
Introduce the audit team, the auditee leadership and audit participants.
Present the audit schedule.
Discuss who has authorized the performance of the audit and why.
Describe how evidence will be collected during the audit.
Review how audit results will be reported.

Participation of leadership at the opening meeting helps communicate support for the audit process and expectations for employee participation in the audit.

Collecting EHS Compliance Audit Evidence

In Part 1 of this series, we discussed how to plan an EHS compliance audit focusing on what matters (materiality). Auditors use the audit plan to develop audit trails that result in positive or negative evidence of compliance. A questions like “tell me about the processes operated in this department” is often a good starting point for developing audit trails. Here is an example follow-up questions an auditor could ask to further develop the compliance audit trails.

Auditor: I see the metal parts grit blast process is operating today. What kind of parts are you blasting now.

Auditee: We are cleaning several hundred parts before they are electroplated.

Auditor: What are some of the important environmental aspects and OHS hazards you need to consider when operating the grit blaster and dust collector when cleaning stainless steel parts?

A well-prepared auditee will have identified the environmental and occupational health and safety regulations before the audit. Figure 1 is an example of a risk analysis tool that helps prepare for an audit and helps auditors identify important areas to audit. For more information about risk analysis watch this Risk Overview brief video. Learn more about CorrectTrack app.

Tools like CorrectTrack provide a listing of environmental aspects and OHS hazards. The list helps quickly identify important aspects and hazards that are good candidates for improvement or for developing audit trails. The highlighted row in Figure 1 is an example of an environmental aspect to check during an audit. Clicking on Risk ID 803 link shows the risk detail page (Figure 2).

Figure 2 – Grit Blast Dust Emission Environmental Risk Detail

This page shows important details about a dust emissions risk and provides links to other information like risk controls, applicable compliance obligations and related files. Clicking on the link under “Files” provides more detailed information (Figure 3). The red box in Figure 3 shows the specific requirements (risks) that need to be addressed or that are (audit criteria) an auditor can check.

Figure 3 – Air Permit Audit Criteria for Dust Collector

Collecting And Evaluating Evidence

An audit checklist can help jog an auditor’s memory of the audit trails they want to follow. Checklists can be as needed. A good checklist points the auditor to what they are trying to prove true. It should be more than a simple check the box yes or no checklist. Check the box checklists discourage looking for and recording evidence of conformity of compliance and should be avoided

The best checklists are prepared by the auditor before or during the onsite portion of the audit. They are specific to the process being audited and the requirement being assessed. The line of questioning can be spontaneous and not always needs to be documented. The questions can be recorded on the spot in the auditors notes along with any evidence observed. Often, audit questions will lead to another question as the auditor follows the audit trail trying to get to the ultimate evidence that a requirement is being met.

Auditor Notes

Auditors need to be able to take good notes during the audit. This helps them recall the details of the audit when preparing the audit report. Notes need to record the evidence the auditor observed during the audit. This can be evidence of conformity or not. Being able to show what the auditor saw or heard during the audit is an important part of the audit process. Good note taking skills are one of the competencies auditors need to possess and continually develop.

Preparing EHS Compliance Audit Findings

Auditor notes are the evidence of conformity, but sometimes the audit shows things are not the way they are supposed to be. Auditors call these nonconformance’s, or potential noncompliance findings. There are many formats for preparing these negative findings. One approach is to write the negative finding in three parts:

1. the requirement,
2. the finding and
3. the evidence that supports the finding

The requirement part of the finding describes the audit criteria the auditor was trying to prove true. It can be a regulatory requirement or a requirement the organization has set for itself. The finding part is a statement of what the problem was, and often refers to the requirements. The evidence part of the audit finding is a summary of what an auditor saw that led them to the conclusion there was a nonconformity.

The following is an example of a negative finding for potential noncompliance with a State issued Title V air emission permit.

Requirement: [s. NR 439.055(2)(a), Wis. Adm. Code, 02-DCF-178] The pressure drop across the dust collector baghouse shall be measured and recorded once every 8 hours of operation or once per day, whichever yields more measurements.
Finding: Auditee not able to produce records of baghouse pressure drop readings
Evidence: No records of metal finishing baghouse pressure drop were able to be produced for 2^nd & 3^rd shift when baghouse was operating in May 2023.

Communicating EHS Compliance Audit Findings

When a negative finding is made auditors should try to get consensus with auditee that the finding is valid. This will help avoid disagreement on the validity of a finding during the closing meeting. This also helps confirm the auditee has a clear understanding of what was wrong so they begin to fix the problem. Well written findings also help auditees identify appropriate corrective actions. A correction is a quick fix to “stop the bleeding”. A corrective action prevents the nonconformity from recurring.

Closing Meeting

A closing meeting should be held for all EHS audits. During the closing meeting the audit team shares the results of the audit with the auditee. The closing meeting should include the following:

Audit findings
Audit conclusions
Audit recommendations (if appropriate)
Circumstances that affected confidence in the audit results
Audit report timing and distribution
Follow-up actions to be taken by the auditors and auditee
Process for appealing an audit finding or conclusion

Conclusion

This is Part 2 of a three-part article about environmental and health and safety (EHS) auditing. Part 1 discussed how to plan an EHS audit. In Part 3 of this series we will explore how to follow-up on an audit including preparing an audit report, approving corrective actions and verifying corrective action effectiveness during subsequent audits.

ECSI provides auditing, consulting and training services to organizations interested in improving their EH&S performance. For more information, contact us.

Pro-Tips for Best EHS Audits (Part 1): Planning An EHS Compliance Audit

Posted on August 11, 2023 by Kevin Lehner

Introduction

Environmental Health and Safety (EHS) audits help organizations confirm that EHS risk is being managed to an acceptable level. Processes for conducting EHS audits continue to evolve. This three-part article will explore why and how EHS audits are performed. The techniques are based on principles of auditing that have been used for many decades by financial accountants. These techniques are now being adapted to audits of EHS performance. EHS audits assess EHS regulatory compliance, management systems conformance and other important areas of EHS performance. This part of the three-part series explores best practices for planning effective EHS audits.

Part 1 – Planning an EHS Audit

Planning an EHS audit starts with understanding the purpose and objective of the audit. Auditors need to understand who is requesting the audit (the audit client) and what the audit results will be used for. This information helps auditors define the scope of the audit and what resources will be needed to achieve the audit objective. Documenting and sharing the audit objective and scope early in the audit planning process helps ensure there is agreement between the auditor and the auditee. Figure 1 is an example of how an auditor might document the audit Objective and Scope as part of developing and EHS audit plan.

Figure 1 – Audit Objective and Scope statement in an audit plan

Determining EHS Audit Duration

With the objective and scope confirmed, an auditor can determine how much time will be required to perform the audit (audit duration). This includes estimating time to plan the audit, collect audit evidence, review the evidence and prepare a report of the audit findings and conclusions. Sometimes the auditor needs to conduct a preliminary Stage 1 audit to help judge auditee readiness, gather additional information to determine the audit duration and confirm the audit is feasible. Differences between the duration proposed by the auditor and what the audit client is willing to pay, need to be resolved before the audit begins. Changing the scope of the audit can often help the auditor and auditee reach consensus on the duration of the audit.

Auditor Competence

The confidence that can be placed in the results of the audit are directly proportional to the auditors competence. Auditor competence includes knowledge of the regulatory requirements (the audit criteria) and the processes that are the subject of the audit. Audit team members should also have developed audit skills including, how to conduct interviews, how to follow audit trails and how to record audit evidence. Auditor behaviors are also critical including maintaining confidentially and making the auditee feel at easy during the audit.

Preparing an EHS Audit Schedule

With the audit duration established competent auditors can now develop and document a plan to conduct the active evidence gathering part of the audit. The plan should identify where the auditor plans to audit, when they plan to be there and what evidence they will be evaluating. It can also include who the auditors intend to interview during the audit. This helps the auditee schedule meetings with the auditor and avoid delays in the audit due to interviewee being unavailable when the auditor desires to conduct the interview.

Confirming the Audit Schedule

Once the audit plan is established it should be shared with the audit client and the auditee to ensure agreement on when, where, and how the audit will be conducted. When agreement is reached the auditor can begin to make plans for travel and accommodations during the onsite portion of the audit. Figure 2 is an example audit schedule for a hypothetical metal parts manufacturing facility that also has an electroplating process.

Figure 2 – Example EHS Compliance Audit Plan

Summary

In this part of the 3-part compliance audit series we explored how to plan an EHS audit. In Part 2 of the series, we will explore how to conduct an EHS audit by following audit trails and recording audit evidence. In part 3 we will explore processes for reporting and following up on the results of an EHS audit.

ECSI provides auditing, consulting and training services to organizations interested in improving their EH&S performance. For more information, contact us.

This is the first of a three-part article that describes best practices for planning, conducting, and following up on environmental and occupational health and safety regulatory compliance audits.

This three-part series we will consider best practices for:

Part 1 – Planning audits
Part 2 – Conducting audits
Part 3 – Following up on audit results

ISO 45001 Webinar – FREE!

Posted on July 29, 2023 by Kevin Lehner

Watch Webinar

ISO 45001 is an international standard that helps organizations improve Occupational Health and Safety (OHS) performance. The ISO 45001 standard can be used to ensure workers are safe by protecting them from workplace injury and ill health. As the Vice Chair of the US Technical Advisory Group to ISO 45001, I have been seeing a significant rise in awareness of ISO 45001 benefits. Environmental Compliance Systems, Inc has also helped many organizations plan, implement and integrate an ISO 45001 OHSMS with their other business management systems. A recent webinar produced with ASSP describes the many benefits of an ISO 45001 OHSMS. Here is a link to free ASSP webinar: https://player.vimeo.com/video/844292169?. Please watch if you are interested in improving your organizations OHS performance.

Definition of Risk in the ISO High Level Structure

Posted on September 12, 2020 by Kevin Lehner

ISO 45001:2018, 14001:2015 and 9001:2015 are based on the High Level Structure. The International Organizations for Standardization (ISO) High Level Structure (HLS) is about to enter another phase of revision of the HLS. The definition of “Risk” in the ISO HLS and the term “risk and opportunity” is causing confusion with drafters and users of ISO 45001.

Removing the special definition of term risk and eliminating use of the term risk and opportunity will help standards drafters reduce ambiguity in the standard requirements and help other users better understand how to plan. implement, operate and audits ISO management systems.. The following discussion is based on our extensive experience auditing, teaching and consulting for ISO 45001, 14001 and 9001.

The Definition of “Risk” and Use of the Term “Risk and Opportunity” in ISO High Level Structure

The HLS was introduced in 2012 to “harmonize” management system standards around a common structure. The common structure helps organizations integrate quality, environmental, health and safety and other management systems.

Figure 1 is the Table of Contents of the HLS as currently proposed in Draft ISO/DGuide 83 – 06/03/2020.

In this post we discuss two issues being raised during the HLS revision process.

These are:

the definition of the term risk in the HLS,
use of the terms risk and opportunity in the HLS.

Resolving these two issues is important to users understanding of what ISO 45001 is designed to manage.

In a previous post, we provided an overview of proposed changes to the HLS duirng the minor revision stage, As the HLS revision begins to enter the major revision stage we believe there are important issues to be addressed by ISO. We believe that ISO should carefully consider the unintended negative consequences of creating a special definition of risk and using the term risk and opportunity in future versions of the HLS.

Risk as a “defined term”.

Definition of risk

The Oxford English Dictionary (OED) is the official dictionary of ISO and defines risk as the “possibility of loss, injury, or other adverse or unwelcome circumstance”. The Merriam-Webster definition is similar, “possibility of injury or ill health”. These definitions of risk have been in use for many decades and with great success by organizations managing Occupational Health & Safety (OH&S) performance.

In 2012 ISO introduced the term risk as a “defined term” giving it a different definition than OED or Merriam -Websters. The HLS definition of risk is now “the effect of uncertainty” (see Figure 2).

The new definition is designed to encourage organizations to take a broader view of both the positive and negative characteristics of risk. This approach is supported by the ISO technical committee that develops guidance standards on risk management (TC 262). ISO 31000 is the flagship standard in this series. ISO 31010 is guidance on risk assessment techniques.

Use of “on objectives” in the HLS definition of risk

TC 262 isnow promoting another revision to the definition of risk that adds the words “on objectives” to the HLS definition of risk They believe the concept of risk cannot be comprehended without reference to the term objectives in the definition of risk (Figure 3).

However, adding the words “on objectives” creates ambiguity and confuse drafters and users of ISO 45001. This is because the term objectives is already used in 45001 referring to specific goals the organization needs to achieve to improve OH&S performance.

The objectives refereed to in the ISO 31000 definition of risk are more broad and include business and societal objectives. The potential unintended consequence of adding the words on objectives to the definition of risk is users will only address risk associated with objectives and not more broadly address OH&S risk to workers and the organization..

Unintended consequences of changing the definition of risk

The addition of a special definition of risk has increased ambiguity about the meaning of the term risk. It has also had unintended consequences for both those using the HLS when developing management system standards, and those using these standard to plan and implement OH&S management systems..

As an example, because of the way ISO has now defined risk, the developers of ISO 45001 found it necessary to add two additional notes to the definition of risk (Figure 4). The ISO 45001 definition of risk now has 6 notes (198 words) to explain the three word definition of term risk.

The drafters of ISO 45001 also found it necessary to create another defined term OH&S risk (Figure 5). This new definition was added to clarify ambiguity caused by the HLS definition of risk and how OH&S professionals had traditionally understood the concept of risk in the OH&S management discipline.

The intent of the new ISO special definition of risk was to shed light on the practice of risk management and encourage organizations to take a broader view of the dynamics between risk and opportunity. That objective may have been achieved but with significant additional confusion by standards drafters and users. ISO should consider removing the special definition of risk from the HLS and return to use of the Oxford English Dictionary of risk.

Risk and Opportunity in the High Level Structure.

The association of the word risk with the word opportunity (risk and opportunity) in HLS clause 6 has confused drafters and users of ISO 45001. There is uncertainty if the term risk and opportunity refers to a single concept or two different concepts. To help explain what is meant by risk and opportunity ISO prepared a white paper titled Risk Based Thinking in ISO 9001:2015. Although the title indicates the topic is ISO 9001 Quality Management systems, the examples used in the white paper are also applicable to an ISO 45001.

To clarify ambiguity about the term risk and opportunity, drafters of ISO 45001 added a new defined term OH&S opportunity (Figure 6).

The ISO 45001 definition of OH&S opportunity refers the concept of OH&S performance improvement, another defined term in ISO 45001 (Figure 7) . The definition of OH&S performance references another 5 defined terms in ISO 45001. The need to create a separate defined term of OH&S opportunity and then refer to 5 other defined terms to explain the OH&S performance, This tortured effort to reduce ambiguity is further evidence of the confusion the term risk and opportunity has introduced to ISO 45001.

ISO 45001 also refers to other risks and other opportunities that the organizations needs to address (Figure 8). These terms are not defined in ISO 45001. This adds uncertainty about the concept of risk and opportunity in ISO 45001.

Figure 8 – ISO 45001 Other Risk and Other Opportunities

These many terms associated with the concept of risk and opportunity in Clause 6 creates uncertainty about what ISO 45001 is supposed to manage. Those implementing, operating and auditing an OHSMS are confused, especially when identifying what is important to the organization’s OH&S performance. The unintended consequence of adding the term risk and opportunity is user confusion about answers to important questions like:

When the HLS uses the term opportunities is it referring to potential financial or societal gain or to a discipline specific intended result such as a safer workplace?
What is the difference between the concept of risks and opportunities and the concept of OH&S risk, OH&S opportunity and other risk and other opportunity or are these the same thing?
Are the concepts of hazards and risks being tre focus of OH&S management systems now obsolete, or can it still be used when planning an OH&S management system?

Conclusion and Recommendation

The introduction of a special definition of risk and the use of the term risk and opportunity in the HLS has led to unintended and unnecessary confusion by drafters and users of ISO 45001. ISO should remove the definition of risk and use of the term risk and opportunity from the ISO HLS. during the next phase of the HLS revision.

Integrating Covid-19 Internal Audits with an ISO 45001 OHSMS

Posted on May 20, 2020 by Kevin Lehner

June 4, 2020

1:00 PM – 1:30 PM – Central Time

The purpose of this brief webinar is to discuss the advantages of using internal audits and corrective actions to check that an organizations Covid-19 program is effective. The webinar explores how organizations can use ISO 45001 management system tools to respond to new challenges from the Covid -19 pandemic.

As the economy reopens organizations are being required to establish new programs and controls to minimize the spread of the virus among employees. Internal audits combined with corrective action programs help organizations establish and operate effective Covid-19 programs rapidly.

The webinar covers the following topics:

Identifying Covid-19 compliance obligations
Risk assessment methods for determining which Covid-19 Risk to addressed
Establish operational controls for Covid-19 risks to employees
When and how often to audit the Covid-19 program
How to safely conduct Covid-19 audits
How to effectively address Covid-19 internal audit findings through corrective action.
Report the results of Covid-19 audits and corrective action to leadership

About the presenter

Kevin Lehner is a member of the US Technical Advisory Group (US-TAG) to ISO 45001: He is an expert and represents the US-TAG at international meetings. He recently traveled to Kigali, Rwanda to attend the 9th international meeting of TC 283 (interview with Martin Cottam in Kigali). Kevin is a certified lead auditor conducting ISO 45001 audits for clients including accredited ISO 45001 certification bodies.

Register for this Webinar

Auditing ISO 45001:2018 – 5.4 Consultation and participation of workers

Posted on July 12, 2018 by Kevin Lehner

Note. I want to be clear upfront that my intention is not to discredit the contribution organized labor made to the development of ISO 45001:2018. The point I make here is that they had a significant impact on the requirements in certain sections of ISO 45001:2018. This fact may help inform users about the intent of the requirements for purposes of implementation and conformity assessment.

Clause 5.4 of ISO 45001:2018 discusses requirements for consultation and participation of workers and is the result of an interest groups desire to ensure their constituents were give certain rights to have influence over the organizations OHSMS. Organized labor got a symbolic win here for their constituents but does this additional language add value to the standard or simply create unnecessary complexity and confusion for users of the standard?

As an auditor my approach would be to check if the workers themselves believe that their opinions about the OHSMS have been considered in its development and implementation. The best way to do this is to ask them directly. Here is a line of questioning I would use to get objective evidence of conformity to the participation and consultation requirements in 5,4 of ISO 45001:2018.

My first question would be something like “Have you heard about the OHSMS here?”. The answer to this question helps me get a sense of the organizations general awareness of the existence of an OHSMS. You might have to rephrase the question to get them to understand what you are asking.

The next questions would be something like… Can you tell me about what you do as your job here and what you do to keep yourself safe from injury or ill health? A good answer would be something like… My job is to load railcars. I need to stand on top of the railcar and inspect it after it is loaded. I need to wear this fall protection harness when I am on the railcar in case I accidently fell off. The harness would break my fall and prevent or reduce my chances of injury.

The next question would go directly to participation and consultation and would be something like this. Did you participate in any of the planning part of the OHSMS giving leadership your opinion of your comfort level with safely performing you job. Another good answer would be something like…Yes, our entire crew participated in a hazard identification and risk assessment meeting where we went over all the job tasks and risks. We were asked if we felt safe doing these tasks given the safety procedures and equipment that was in place. One of the areas we raised as potentially unsafe was the absence of fall protection. Based on that, our leadership has provided us with these ladders, harnesses and showed us how to use them. I feel much safer now with this enhanced risk control.

Based on the results of this interview I would have good objective evidence that the intent of 5.4 had been achieved. If most other worker interviewed had a similar tale to tell I would feel comfortable in concluding that the organizations had meet the requirements of clause 5.4 of the standard.

Of course, this line if questioning could have gone in many other directions and the answers given may not have supported a finding of conformity to varying degrees. Auditors are certified and calibrated to make decisions during audits while considering all the evidence presented much like a judge does in a legal case. Auditors who focus on too much detail like expecting the auditee to produce evidence of each of the 21 individual requirements of 5.4 are missing the point and need to step back and look at the bigger picture.

A True Story – Why ISO 14001 Works

Posted on January 6, 2013 by Kevin Lehner

Background

It has been over seven years since we first began helping a medium sized automotive equipment manufacturer in the midwest implement a company wide ISO 14001 EMS. They were getting pressure from their customers to prove they were good environmental performers and an ISO 14001 certificate was the best solution. We helped them with environmental aspects, setting up the EMS and identifying regulatory compliance requirements. As we were completing the project we performed a round of internal audits to check that each facility was complying with the applicable legal requirements.

The Audit Finding

One of the findings of our compliance audit was that at one location, the company was operating unpermitted production painting equipment. The audit team could find no records of correspondence with the State permitting authority about this new equipment. It had been commissioned sometime after an initial Title V permit application had been prepared for the facility. The paint operation was an important part of the manufacturing process and it was not possible to simply shut the process down. Doing so would have resulted in delayed shipment of product and dissatisfied customers.

The Response

Although the discovery of this potential noncompliance was uncomfortable news for the organization, at least they now had a better picture of the potential risks they were facing. They examined the process closely and decided that it was time to upgrade. They worked it out with the state permitting authority to replace the old system with a new more efficient paint system.

Fast Forward

Over the last several years we have continued to perform periodic EH&S compliance, ISO 14001, and OHSAS 18001 internal audits to support their continued certification to these standards.. During a recent compliance audit at one of the facilities we were delighted to see a new process being installed. It means the company continues to grow but, from an auditors perspective, the stack ducting through the roof becomes a great opportunity to check the EMS effectiveness to control noncompliance risk. As we walked by the new process I could see the auditee cracking a half smile as I asked a few questions about the new equipment and construction underway. He knew where this audit was going.

The audit was actually a combined one-day environmental and OSHA compliance audit so we had a lot of ground to cover in 8 hours. When the audit schedule called for review of compliance with state air emission permits, I asked what they knew about the potential emission from the new process. The audtee said “the process had the potential to emit a hazardous air pollutant at levels requiring permitting before installation of the equipment”. The auditee then produced the construction permit they had been issued by the state? The EMS had worked to help the organization identify the need to obtain a permit, well in advance of beginning construction on the new process.

Results Matter

Discovery of unpermitted emission sources during internal and compliance audits is not uncommon for us even today. Helping organizations identify and manage risks of noncompliance in the short term provides some satisfaction in our work. But having the opportunity to see the results of an effective EMS that we helped implement and, how that EMS has helped manage risks long term, is particularly gratifying.

Skepticism of the benefits of ISO 14001 will continue to linger especially with the uniformed. However, organizations interested in managing environmental risk and becoming more sustainable need to understand how the audit processes, embedded in ISO 14001, can be used to support an organizations sustainability efforts, promote successful outcomes and provide confidence by other stakeholder that environmentally, things are as they should be.

Disappointing News from ANAB

Posted on July 6, 2012 by Kevin Lehner

In late spring we meet with ANAB at their headquarters in Milwaukee to kick off the process of becoming an ANAB accredited registrar. Our hope was to issue ISO 14001, OHSAS 18001 and ISO 50001 accredited certificates to business in the upper Midwest. To our surprise during that meeting ANAB made it clear that consultancies are prohibited from accreditation as certification bodies. In ANABs eyes consultancies and anyone involved in governance of a consultancy is incapable of impartiality when performing ISO certification assessments.

We continue to believe that consultants make good auditors and vice versa. The financial audit sector (accounts) has operated successfully for many decades using the model to ensure competency of both auditors and consultants. We believe that ANAB, IAF and ISO’s conclusion that the threats to impartiality by consultancies are irreconcilable is not based in fact. We also believe that the threats of financial self-interest by ANAB accredited certification bodies are at least as potent as any threat to impartiality from a consultancy performing certification activities. This is because accredited CBs can (or should) only be allowed to generate revenue from one source, their certification activities.

We remain committed to trying to work with ANAB to find a way to offer ISO certification services in the upper Midwest but for the time being have placed this lower on our priority list of objectives.

Here Come the Bean Counters!

Posted on March 2, 2012 by Kevin Lehner

Having lead hundreds of sustainability performance assurance engagements over the last several decades I admit bias but have seen first hand evidence that organizations exaggerate and in some cases misrepresent their sustainability performance. This is especially true when the marketing departments are tasked with the job of turning an organization green.

As non-financial sustainability performance information is relied upon to make important decisions about investment and other business relationships, assurance of organizations sustainability performance assertions will become more common. An important question is who will do this assurance work? Recognizing opportunity the financial accounting profession is hard at work tooling up to fill this emerging niche http://www.ifac.org/publications-resources/ifac-sustainability-framework-20

The confidences stakeholders can place in the results of an assurance engagement are directly proportional to the competence of those performing the audits. It will be interesting to see how the bean counters do at assessing environmental, health, safety and social performance as they endeavor to to learn the practice in this market.