Internal Audit Results - MSD

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Internal Audit Results - MSD

National Biosolids PartnershipLouisville Green Management System Internal Audit Report #7Audit Report Date: August 2, 2012Audit Conducted By:Robin BurchJoe FalleriAdraine NiehoffJenni SchellingAudit Dates: June 11-13, 2012Report Written By: Robin BurchLouisville and Jefferson CountyMetropolitan Sewer DistrictLouisville, KY


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Auditor’s Opinion StatementLouisville and Jefferson County Metropolitan Sewer District (MSD) continues itscommitment to the policy, the National Biosolids Partnership (NBP’s) Code of GoodPractice and the 17 Elements. The auditors believe MSD continues to have afunctioning Louisville Green Management System (LGMS). The LGMS is currentlyin Year 4, (for a total of five years) as it is evident to the auditors the system hasreached its maturity for most Element requirements.However, seven (7) minor nonconformances were identified during this InterimAudit. The majority of the nonconformances center around Goals and Objectives.Improvement in this area continues, however, the auditors believe additionalresources are needed.Report Date: August 2, 2012 Page 2 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Table of ContentsAuditor’s Opinion Statement...................................................................................... 21. Summary............................................................................................................ 41A. Audit Scope .................................................................................................41B. Summary of Audit Findings .............................................................................51C. Distribution Plan..............................................................................................52. Audit Details ...................................................................................................... 62A. Agency Details ................................................................................................62B. Definitions .......................................................................................................62C. Reference Materials .........................................................................................73. Effectiveness Review ......................................................................................... 74. Detailed Audit Results ..................................................................................... 10Element 1 – Documentation of LGMS Manual for Biosolids ................................ 10Element 2 -- Biosolids Management Policy ......................................................... 11Element 3 -- Critical Control Points .................................................................... 12Element 4 – Legal and Other Requirements ......................................................... 14Element 5 – Goals and Objectives for Continual Improvement ............................. 14Element 6 – Public Participation in Planning ........................................................ 16Element 7 – Roles and Responsibilities ................................................................ 17Element 8 – Training............................................................................................ 18Element 9 – Communication ................................................................................ 19Element 10 – Operational Controls of Critical Control Points............................... 20Element 11 -- Emergency Preparedness and Response ........................................ 21Element 12 – EMS Documentation, Document Control and Recordkeeping ......... 22Element 13 -- Monitoring and Measurement ....................................................... 23Element 14 – Nonconformances: Preventative and Corrective Actions ................. 24Element 15 -- Biosolids Management Program Performance Report ................... 25Element 16 -- Internal LGMS Audit .................................................................... 26Element 17 -- Management Review .................................................................... 275. Appendices ...................................................................................................... 29A. List of Requested Resources ...................................................................... 29B. List of Reviewed Documents ..................................................................... 29C. Auditor Qualifications ............................................................................... 30Report Date: August 2, 2012 Page 3 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 20121. SummaryThe Internal Audit Team, hereafter known as the “auditors”, conducted the seventhinternal audit of the Louisville Green Management System (LGMS). The system isused by Louisville and Jefferson County Metropolitan Sewer District (MSD) inmanaging its biosolids program at the Morris Forman Water Quality TreatmentCenter (MFWQTC). The audit was performed June 11-13, 2012.The objective of the internal audit was to evaluate the LGMS, how it conforms to theLGMS policy and the National Biosolids Partnership (NBP) EnvironmentalManagement System for Biosolids Code of Good Practice and its 17 elements.1A. Audit ScopeThis year’s Internal Audit is being substituted for the year four Interim Audit. Tomeet the National Biosolids Partnerships requirements, the Internal Audit will includea review of the following:BMP Outcomes (Environmental Performance, RegulatoryCompliance, Interested Party Relations, Quality Practices)Progress Toward Goals and ObjectivesActions Taken to Correct Minor NonconformancesCorrective Action Requests and ResponsesPreventive Action RequestsManagement ReviewIn addition, the Internal Audit will include a review of the following Elements, asagreed upon from the Third Party Auditor’s Audit Plan:Element 2 – PolicyElement 3 – Critical Control PointsElement 12 – Document ControlElement 14 – Corrective ActionsElement 16 – Internal AuditsReport Date: August 2, 2012 Page 4 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 20121B. Summary of Audit FindingsNonconformancesThe auditors identified seven (7) minor nonconformances as they relate to therequired elements set forth by the NBP. These nonconformances are described indetail in Section 4 of this report.Opportunities for ImprovementThe auditors also identified five (5) opportunities for improvement. Theseopportunities are described in detail in Section 4 of this report.1C. Distribution PlanThe LGMS Core Team will receive a draft version of the audit report. This reviewperiod will take no longer than 2 weeks. The Core Team will meet with the auditteam to discuss the report and any required changes will be addressed. The finaldocument will then be sent to the Process Support Technician and to distributeaccordingly. The Core Team will submit a corrective action plan to the auditors forreview within 30 days of receipt of the final audit report. The Process SupportTechnician will then have 90 days to implement the corrective action plan.Report Date: August 2, 2012 Page 5 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 20122. Audit Details2A. Agency DetailsContractors AuditedNoneAudit TeamAgency Name: Louisville and Jefferson County MSDAddress: 4522 Algonquin Parkway, Louisville, KYVolume of Wastewater 120 MGD Average, 330 MGD PeakTreated:Biosolids Produced: 25,000 dry tons per yearNumber of Employees: 90The Internal Audit Team consists of the following MSD personnel:Robin Burch – Process Support Technician, Lead AuditorJoe Falleri – Operations Process SpecialistAdraine Niehoff – Emergency Response Pretreatment InspectorJenni Schelling – Internal AuditorAuditor Qualifications are given in Appendix C.2B. DefinitionsMajor Nonconformance – a serious omission from requirements and/or otherdeparture that represents, or could cause, a systemic failure.Minor Nonconformance – an isolated departure from requirements that does notrepresent a systemic failure.Opportunity for Improvement – possible improvement in the LGMS based on auditorobservations.Report Date: August 2, 2012 Page 6 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 20122C. Reference MaterialsThe following materials were used as a reference by the auditors during the internalaudit:Louisville and Jefferson County LGMS Manual, June 2009National Biosolids Partnership National Manual of Good Practice forBiosolids, January 2005National Biosolids Partnership Management System GuidanceManual, June 20023. Effectiveness ReviewBMP OutcomesA review of the Biosolids Management Program Outcomes was conducted toinclude the four key outcome areas listed below:Environmental PerformanceThe LGMS continues to identify priorities for improvingenvironmental performance when establishing Goals and Objectives.The auditors found several of the current Goals and Objectives directlyrelated to Environmental Impacts identified in the program.Regulatory ComplianceThe LGMS continues to meet the EPA 503 requirements for Class AEQ Biosolids. During the audit period, there had been an exceedencethat required landfill of the Biosolids due to elevated Cadmium.However, due to the controls in place, no Biosolids were land appliedwith the elevated Cadmium.Interested Party RelationshipsInterested Party Relationships continue for developed markets.Additional efforts should be made to receive public input andparticipation in the Louisville Area. Awareness of Louisville Green’sapplications in the local community is imperative to the success of theproduct.Report Date: August 2, 2012 Page 7 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Quality Biosolids Management Practices:The LGMS remains committed to the Code of Good Practice:1. Compliance – MSD continues to comply with all applicablefederal, state and local laws and requirements regarding Biosolidsproduction at the wastewater treatment facility and management,transportation, storage, and use of its Biosolids away from thetreatment facility. During the audit period, there have been noinstances of noncompliance with laws, transportation, storage oruse incidents reported.2. Product – MSD continues to provide Biosolids that meet or exceedapplicable standards for their intended use or disposal. During theaudit period 100% of distributed material was beneficially reused.3. Environmental Management System – MSD has developed aLouisville Green Management System (LGMS) for Biosolids thatincludes a method of independent third-party verification to ensureeffective ongoing Biosolids operations. Resources continue to bededicated to the LGMS.4. Quality Monitoring – MSD continues to enhance the monitoring ofthe Biosolids production and management practices. During theaudit period, a new monitoring and measurement protocol has beendeveloped to aid in product sizing.5. Quality Practices – MSD continues to encourage goodhousekeeping practices for Biosolids production, processing,transport and storage and during final use or disposal operations.However, during the audit, the housekeeping in general wasunacceptable.6. Contingency and Emergency Response Plans – MSD hasdeveloped response plans for unanticipated events such asinclement weather, spills and equipment malfunctions.7. Sustainable Management Practices and Operations – MSDcontinues to enhance the environment by committing tosustainable, environmentally acceptable Biosolids managementpractices and operations through an environmental managementsystem. During the audit period, a project has been started torefurbish the Solids Handling Odor Control (SHOC). When theproject is complete, all odorous air from the Solids HandlingProcess will be treated by the SHOC instead of the FumeIncinerator. This is estimated to save $600 per day, or $219,000per year.Report Date: August 2, 2012 Page 8 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 20128. Preventative Maintenance – MSD continues to develop andimplement a plan for preventative maintenance for equipment usedto manage Biosolids and wastewater solids. The PreventativeMaintenance completion goal continues to be met however thereneeds to be additional documentation of the process to meetelement requirements.9. Continuous Improvement – MSD continuously seeks improvementin all aspects of Biosolids management. During the audit period, anew coating oil was purchased and is estimated to reduce oil costby 40% or approximately $58,000 per year.10. Communications – MSD is providing methods of effectivecommunication with gatekeepers, stakeholders, and interestedcitizens regarding the key elements of each environmentalmanagement system, including information relative to systemperformance. MSD’s website is up to date with informationregarding Louisville Green. Quality Feedback continues to bereceived from Interested Parties and the Sales Agent.Progress Toward Goals and ObjectivesIt is the opinion of the auditors the LG Management team has made progress towardGoals and Objectives. Eight objectives have been identified by the team. Theobjectives continue to focus on LGMS related activities but are starting to spread toother areas of the treatment center.Actions Taken to Correct Minor NonconformancesThe auditors have reviewed all the nonconformances from the Third Party Auditconducted in June 2011 and have determined the actions taken are sufficient tocorrect the deficiencies. However, these nonconformances must remain open untilthe next 3 rd Party Audit where they will be reviewed and closed by the 3 rd PartyAuditor.Management Review ProcessThe Management Review Process continues to bring in diversified discussion frommanagement staff that are not involved with the day to day activities of LouisvilleGreen. This is expected to continue as new management staff are being added to theorganization. It is the opinion of the auditors that the Management Review Processrequired by Element 17 is effective.Report Date: August 2, 2012 Page 9 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Corrective Action/Preventive Request and ResponsesThe Corrective/Preventative Action Plan Spreadsheet maintained by the EMSCoordinator provides sufficient information to allow the auditors to track thecorrective actions from internal or third party audit. It is the opinion of the auditorsthat additional resources should be given for routine or preventive request andresponses.4. Detailed Audit ResultsThe auditors made the following observations with respect to each element during theaudit process:Element 1 – Documentation of LGMS Manual for BiosolidsProcess DescriptionThe LGMS manual is the foundation for the implementation of an effective biosolidsprogram. Revision 10 dated 6-23-11 is the current version of the manual.Element Requirements (From the Guidance Manual)The environmental management system for biosolids (including the other 16 LGMSElements) shall be documented in an LGMS manual or equivalent set of programdocuments that describe, at least at a general level, the applicable policies, programs,plans, procedures and management practices in the LGMS. The LGMS manual shall:1. Be approved by a level of the organization’s management with theauthority to commit people and resources to biosolids managementactivities.2. Contain the organization’s biosolids management policy and LGMSprocedures required by the LGMS Elements.3. Contain or cross-reference public participation in planning,communication, and emergency preparedness and response programs andplans required by the LGMS Elements.4. Cover all critical control points for its biosolids management activitiesthroughout the biosolids value chain.5. Include or cross-reference all operational controls, procedures, processes,and other management methods used to achieve and maintain compliancewith legal and other requirements.6. Describe those biosolids management activities assigned to and performedby contractors.Report Date: August 2, 2012 Page 10 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Results1. The LGMS Manual is approved by the Wastewater Process Manager. Theapproval for all controlled documents is designated by “Approved By” oneach document. In addition, a signature needs to be required of theapproving authority for the specific controlled document. MinorNonconformance 01Management Response – The “Approved By” designation on thecontrolled documents for approval will remain. A new revision of acontrolled document will be signed or initialed by a Wastewater ProcessManager once reviewed. The signed copy will then be scanned to the EMSdrive and become the printable version of the controlled document. Theoriginal will be stamped “original” and placed in the resource libraryEMS file cabinets. Implementation of this procedure will occur beforeAugust 31, 2012.2. Conforms.3. Conforms.4. Conforms.5. Conforms.6. Conforms.Element 2 -- Biosolids Management PolicyProcess DescriptionThe LGMS policy is the guiding principle to establish what the organization wants togain from the program. MSD continues to operate in adherence to the policy and theCode of Good Practice set forth in the LGMS Manual and NBP.Element Requirements (From the Guidance Manual)1. The organization shall establish a biosolids management policy (biosolidspolicy) that commits the organization to following the principles of conductset forth in the National Biosolids Partnership’s Code of Good Practice andmay include other biosolids commitments the organization voluntarilychooses to adopt.2. The organization’s biosolids management policy shall be communicated toemployees, contractors, and all interested parties and be incorporated intothe organization’s biosolids programs, procedures, and practices.3. Biosolids policy approved by Management.4. Incorporate the Policy into MSD’s Biosolids programs, procedures andpractices.Report Date: August 2, 2012 Page 11 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Results1. The Code of Good Practice is not being followed: 5. Quality Practices.The auditors observed poor housekeeping in multiple areas of the facility.Cleaning assignments are developed for each area but are not beingfollowed, enforced or documented. 8. Preventative Maintenance:Additional procedures need to be added to the LGMS manual to documentthe Preventative Maintenance activities. Minor Nonconformance 02Management Response – The Wastewater Process Managers and theMaintenance Manager will review the current cleaning assignments todetermine if they are appropriate. Revisions are to be made wherenecessary. The cleaning assignments will then be discussed at the nextsupervisors meeting on August 14, 2012. Full implementation will becomplete by August 31, 2012.2. Conforms.3. Conforms.4. Conforms.Element 3 -- Critical Control PointsProcess DescriptionCritical Control Points (Appendix 3A) should be identified in all area of the biosolidsvalue chain. Each critical control point is fundamental to operating a successfulLGMS.Element Requirements (From the Guidance Manual)1. The organization shall identify and document the critical control points ofits biosolids management activities throughout the biosolids value chain.2. The organization shall also identify potential or actual environmentalimpacts at each critical control point.3. The organization’s critical control points shall be consistent with thoseidentified in the NBP’s National Manual of Good Practice and otherauthoritative sources on biosolids management.4. The information on the organization’s critical control points shall be keptup to date and the records shall link each critical control point and itspotential environmental impacts with the corresponding operationalcontrol(s).Report Date: August 2, 2012 Page 12 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Results5. Organizations that have successfully completed a third-party verificationaudit shall provide notification to the NBP (and third-party verificationauditor) after any operational change that requires a change to theidentified critical control points or to environmental impacts associatedwith the critical control points.1. Conforms.2. Not all Critical Control Points have Environmental Impacts identified.Specifically the Dewatering and the Landfilling of Biosolids. MinorNonconformance 03Management Response – A meeting has been set for July 31, 2012 withthe Wastewater Process Managers and the Process Support Technician.Critical Control Points and their Environmental Impacts will be reviewedand changed as needed. Final approval will be complete before August31, 2012.3. Conforms.4. Conforms.5. Conforms.Opportunity for ImprovementOpportunity 01 -- Appendix 3A List of Critical Control Points. The auditorssuggest the format of this document be changed to maintain consistency. There aremany locations in the document where the “ditto mark” is used. There are otherlocations (i.e. the Environmental Impacts column) where it looks like the ditto markshould be use, but is not. Additionally, consistent formatting should be used formany line items what would create a cleaner appearance.Management Response – The format of Appendix 3A – List of Critical Control Pointswill be modified. A meeting has been set for Tuesday July 31, 2012 with the ProcessSupport Technician and the Wastewater Process Manager for discussion.Opportunity 02 -- Documentation should be developed so the history of changes ofthe Critical Control Points can be established and tracked.Management Response – This change will take place in the next revision of Appendix3A – List of Critical Control Points. The next revision will be complete by August 31,2012 to address Nonconformance 03.Report Date: August 2, 2012 Page 13 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Element 4 – Legal and Other RequirementsProcess DescriptionThe LGMS manual Appendix 4A List of Legal and Other Requirements, contains allthe necessary information for the value chain. Each member of the LGMS CoreTeam has a responsibility for keeping track of changing regulations andcommunicating these changes back to the team.Element Requirements (From the Guidance Manual)Audit Results1. Establish a procedure for identifying and tracking legal and otherrequirements applicable to its biosolids management activities.2. Establish and maintain records of applicable legal and otherrequirements.3. Include a management process for incorporating changes and newrequirements into the element of the LGMS.Element not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Element 5 – Goals and Objectives for Continual ImprovementProcess DescriptionGoals and objectives are key to the continuous improvement process. Goals andobjectives have been identified for value chain processes with emphasis on the fourkey area outcomes.Element Requirements (From the Guidance Manual)1. The organization shall establish and periodically review measurablebiosolids program goals and objectives for its biosolids managementactivities.2. The organization’s goals and objectives shall reflect identified prioritiesfor improving the environmental performance of its biosolids managementactivities based on its critical control points, identified or potentialReport Date: August 2, 2012 Page 14 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Resultsenvironmental impacts, legal and other requirements, and applicable bestmanagement practices as defined in the NBP’s National Manual of GoodPractice and various authoritative information sources on biosolidsmanagement (e.g., Water Environment Federation manuals of practice).3. The biosolids program goals and objectives also shall consider input frominterested parties developed through proactive public participation.4. The biosolids program goals and objectives shall be integrated with otherElements of its LGMS.5. The biosolids program goals and objectives shall be develop anddocumented using SMART criteria (i.e., be Specific, Measurable,Achievable, Relevant, and Time-bounded).6. The biosolids program goals and objectives shall be updated on a regularbasis.7. The organization shall establish an action plan that describes thoseimprovement activities it is pursuing to achieve its biosolids programgoals and objectives. The action plan shall designate schedules,milestones, resources, and responsibilities for achieving its biosolidsprogram goals and objectives.1. Conforms.2. Conforms.3. Conforms.4. Conforms.5. Objectives 1a and 4c are not time bounded. The target date does not agreewith the goal date on the action plan. Minor Nonconformance 04Objective 1a has not been updated. The objective was not achieved by thetarget date nor was it updated with status or additional resources that manybe needed. Minor Nonconformance 056. Program Goals and Objectives were updated without the approval of theWastewater Process Manager as is stated in Chapter 3: Roles andResponsibilities. Minor Nonconformance 067. The action plan is not consistent in descriptions, schedules, milestones,resources or responsibilities to achieve the goal or objective. Some areadequate in determining the status, but some are not described in sufficientdetail to determine what is actually being updated. MinorNonconformance 07Management Response to Nonconformance 4, 5 and 7 – A meetingbetween all Shift Supervisors and Wastewater Process Managers has beenset for August 6, 2012 to discuss the progress toward goals and objectives.At this meeting, the action plan will be updated with all information foundReport Date: August 2, 2012 Page 15 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012deficient in the audit. Additionally, meetings have been scheduled bimonthlyto prevent any reoccurrences.Management Response to Nonconformance 6 - The “Approved By”designation on the controlled documents for approval will remain. A newrevision of a controlled document will be signed or initialed by aWastewater Process Manager once reviewed. The signed copy will thenbe scanned to the EMS drive and become the printable version of thecontrolled document. The original will be stamped “original” and placedin the resource library EMS file cabinets. Implementation of thisprocedure will occur before August 31, 2012.Opportunity for ImprovementOpportunity 03 -- Objective 1B, 3A, 4A should be re-evaluated to determine if theymeet the requirements of the S.M.A.R.T. criteria. (Specific, Measurable, Attainable,Relevant, Time bounded)Management Response – The objectives will be re-evaluated at the August 6, 2012progress towards goals and objectives meeting.Element 6 – Public Participation in PlanningProcess DescriptionPublic acceptance is a key element for the success of a biosolids program. Publicparticipation is included in many aspects of the planning process as related to the 17Elements. The Core Team is proficient in documenting information given at publicforums and information received from other interested parties. Input received isdiscussed at regular intervals during management meetings. The EMS Coordinatormaintains an interested party list and updates the public participation file as needed.Element Requirements (From the Guidance Manual)1. The organization shall select and implement a proactive publicparticipation approach to involve interested parties in its biosolidsmanagement program and LGMS planning process.2. The approach selected for public participation shall reflect theorganization’s commitments to ten (10) principles in the NBP’s Code ofGood Practice, including its plan for independent third-party verificationof conformance with the LGMS Elements.Report Date: August 2, 2012 Page 16 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Results3. The public participation approach shall be consistent with the degree ofcurrent public interest, the history of public involvement, the method ofbiosolids management, and related local circumstances.4. The approach selected for public participation also shall provide interestedparties with meaningful opportunities to express their views andperspectives relative to the organization’s biosolids management activities,including concerns about environmental impacts, biosolids programperformance, and potential areas for improvement.5. The organization shall consider input from interested parties in initiallydeveloping its biosolids program goals and objectives during its LGMSimplementation and in updating them as part of its periodic review ofbiosolids management program performance.Element not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Element 7 – Roles and ResponsibilitiesProcess DescriptionRoles and responsibilities are the first step in implementing the LGMS. MSD hasdocumented the roles and responsibilities of all employees with biosolidsexpectations. However, they are not broken down into specific operatorresponsibilities per process area.Element Requirements (From the Guidance Manual)1. The organization shall establish and maintain records of the assigned rolesand responsibilities for its biosolids management program and activities.These records shall define and document roles and responsibilities of itsemployees for performing its biosolids management activities and LGMSfunctions.2. Appoint an individual with overall responsibility for ensuring that itsbiosolids management program and LGMS are implemented andmaintained.3. Provide the human, technical, and financial resources necessary to executethese responsibilities effectively.Report Date: August 2, 2012 Page 17 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 20124. Define and document the roles and responsibilities of contractor(s)retained to perform various biosolids management activities and EMSfunctions through service agreements.Audit ResultsElement not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Element 8 – TrainingProcess DescriptionTraining is a critical point for having a successful LGMS. In addition to trainingdocumentation, employees are required to participate in live training opportunitieswith qualified individuals.Element Requirements (From the Guidance Manual)1. The organization shall establish and maintain a training program to ensurethat its employees responsible for specific biosolids management activitiesand for implementing various LGMS functions are competent inperforming their assigned tasks and duties. The training program shallprovide general awareness of the LGMS and how each employee’sassigned roles and responsibilities relate to the entire biosolids valuechain.2. The training program shall address new or reassigned employees.3. The organization shall maintain records of individual employee trainingdelivered and completed.4. The organization shall require that its contractors establish their owntraining programs consistent with their roles and responsibilities inbiosolids management activities as defined through service agreements.Audit ResultsElement not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Report Date: August 2, 2012 Page 18 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Element 9 – CommunicationProcess DescriptionCommunication about the LGMS Program must exist internally and externally. Bothhave key components that must be presented to employees, stakeholders and thepublic to have an effective LGMS. MSD maintains many avenues forcommunication both externally and internally. Creative ways of communication arealways being investigated to make sure interested parties stay engaged in the process.Element Requirements (From the Guidance Manual)1. The organization shall establish and maintain a proactive communicationsprogram that provides on-going information about its biosolidsmanagement program and its LGMS to interested parties and the public,consistent with local circumstances, the method of biosolids management,its public communications history, and degree of current interest in itsbiosolids management activities. The organization’s communicationprogram shall make available a summary of its independent, third-partyLGMS verification audit results to the public.2. The communication program shall include a procedure for receivinginquires and requests for information from interested parties about itsbiosolids management activities and LGMS. The procedure shall define aprocess for ensuring a timely and complete response to inquiries byinterested parties.3. At a minimum, the organization’s communications program shall makethe following information about the organization’s biosolids managementprogram and activities available to interested parties:a. Biosolids management policyb. Applicable legal and other requirementsc. Biosolids program goals and objectives for continual improvementd. Periodic biosolids management program performance reporte. Detailed report of its independent, third-party LGMS verification auditresults4. Define roles and responsibilities of outside contractors in thecommunication plan.5. The organization’s communications program also shall communicaterelevant information about its biosolids management activities and itsbiosolids management policy and all 17 Elements of its EMS to itsemployees and outside contractors, consistent with their assigned biosolidsmanagement roles and responsibilities.Report Date: August 2, 2012 Page 19 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit ResultsElement not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Element 10 – Operational Controls of Critical Control PointsProcess DescriptionOperational Controls are essential in identifying if the day to day activities aremeeting and maintaining the policy, legal and other requirements, as well as theenvironmental impacts.Element Requirements (From the Guidance Manual)Audit Results1. The organization shall develop and implement standard operatingprocedures, work management practices, or other appropriate methods atall critical control points throughout the biosolids value chain to managepotential environmental impacts effectively.2. Operational controls at critical control points shall incorporate all legaland other adopted requirements.3. Operational controls shall consider applicable best-management practicesas defined in various authoritative information sources on biosolidsmanagement (e.g. NBP National Manual of Good Practice, WaterEnvironment Federation manuals of practice, etc.).4. Operational controls shall include appropriate preventive maintenanceprocedures and work management systems for maintaining equipment,instrumentation, vehicles, and other treatment technology and processcontrol systems associated with its biosolids management activities.5. The organization shall require that its contractors establish their ownoperational controls consistent with their roles and responsibilities inbiosolids management activities.Element not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Report Date: August 2, 2012 Page 20 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Element 11 -- Emergency Preparedness and ResponseProcess DescriptionMSD has prepared and implemented an emergency response program for the entirefacility. Employees receive hazardous material, communication, fire extinguisher,CPR and respiratory training each year. Emergency response equipment is inspectedon a monthly basis for readiness. Employees are trained as Emergency ResponseTechnicians and have update yearly training. Plant wide emergency drills areconducted at least annually and in some instances more frequently.Element Requirements (From the Guidance Manual)Audit Results1. The organization shall establish and maintain emergency preparedness andresponse plans and procedures to ensure effective response to accidentsand emergency situations associated with its biosolids managementactivities.2. The organization shall review and evaluate the effectiveness of itsemergency preparedness and response procedures, includingcommunications systems, and revise them as necessary.3. All emergency response equipment shall be on site or readily availablewithin a minimum response time.4. The organization shall require its contractors to establish and maintainemergency preparedness and response plans and procedures to ensureeffective response to accidents and emergency situations associated withits biosolids management activities.Element not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Report Date: August 2, 2012 Page 21 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Element 12 – EMS Documentation, Document Control andRecordkeepingProcess DescriptionThe EMS Coordinator has put together an extensive internal network drive to ensureemployees with biosolids responsibilities have access to all LGMS relateddocumentation.Element Requirements (From the Guidance Manual)Audit Results1. The organization shall establish and maintain document controlprocedures and practices to ensure that its biosolids management programdocumentation and documents are:a. Available and can be located easilyb. Created following established document creation protocolsc. Kept up to date through periodic reviews and revisions (if applicable)d. Properly marked with version number, effective date(s), and referencesto replaced or superceded versionse. Approved by authorized personnel2. The organization shall establish and maintain records of its biosolidsmanagement activities and ensure that they are:a. Available and can be located easilyb. Retained for the specified period of time3. The organization shall establish LGMS documentation, document control,and records requirements for biosolids management activities conductedby its contractors in service agreements, and incorporate theserequirements into its LGMS for biosolids.1. Conforms.2. Conforms.3. Conforms.Report Date: August 2, 2012 Page 22 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Element 13 -- Monitoring and MeasurementProcess DescriptionA systemic approach must be developed for monitoring and measurement to ensurethe programs goals and objectives and operational controls are being met.MFWQTC has an onsite laboratory responsible for all process, discharge monitoringrequired analyses, and pretreatment/ compliance industrial waste monitoring. Thelaboratory maintains a quality assurance program which includes SOP’s and a QualityAssurance Manual.A third party laboratory is responsible for the specific AOAC testing required by EPA503. Results continue to show available Nitrogen above the guaranteed value of 5%.Progress continues in each process area as more information is beginning to becontrolled in real time.Element Requirements (From the Guidance Manual)Audit Results1. Establish and maintain regular monitoring and measurement proceduresand practices for all biosolids management activities to accomplish thefollowing:a) Ensure compliance with applicable legal and other requirements.b) Measure biosolids program performance at critical control points.c) Track progress toward achieving program goals and objectives2. Record monitoring and measurement results and maintain records asestablished in the recordkeeping procedures under Element 12.3. Require contractors to establish and maintain regular monitoring andmeasurement procedures and practices for all their assigned biosolidsmanagement activities, as defined in their service agreements.Element not included in the scope of this audit. This Element was reviewed inthe June 2010 Internal Audit and will be included in the 3 rd Party VerificationAudit in June 2013.Report Date: August 2, 2012 Page 23 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Element 14 – Nonconformances: Preventative andCorrective ActionsProcess DescriptionThe EMS Coordinator does a good job in documenting nonconformances identified ininternal and external audits.Element Requirements (From the Guidance Manual)1. Develop and implement a procedure to investigate any noncompliancewith applicable regulatory requirements or nonconformance with internalLGMS procedures identified during routine monitoring and measurementor periodic internal LGMS audits.2. Develop and implement a procedure to identify the cause and take actionsto correct the nonconformance.3. Develop and implement a procedure to document the necessary correctiveaction to prevent a reoccurrence.4. Develop corrective action plans to address non conformances identifiedduring routine monitoring and measurement and identify thenonconformance, the root cause(s), and the corrective action being taken.In the corrective action plans, identify changes to policies, programs,plans, operational controls, and monitoring and measurement proceduresto prevent future nonconformances.5. Establish formal corrective action plans to address findings of internalLGMS audits and audits conducted by third parties. Document correctiveaction plans and describe what actions will be taken to address the auditfindings, the individuals responsible, the estimated completion date, andrequired resources to develop and implement corrective and preventiveaction. Include recommended changes to policies, programs, plans,operational controls, and monitoring and measurement procedures toprevent future nonconformances. Document these changes in thecorrective action plan and in the LGMS manual and other relevant LGMSdocumentation.6. Track progress in completing the corrective actions and periodicallyupdate to reflect completion.Audit Results1. Conforms.2. Conforms.Report Date: August 2, 2012 Page 24 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 20123. Conforms.4. Conforms.5. Conforms.6. Conforms.Opportunity for ImprovementOpportunity 04 -- Best management practices would insist all minutes from officialmeetings to be reviewed and approved by appropriate personnel.Management Response – Meeting minutes will be reviewed and approved byappropriate personnel.Opportunity 05 -- Currently there are three different ways to track correctiveactions and preventative maintenance. A consistent method should be developed andmaintained.Management Response - The method used to track corrective actions andpreventative maintenance will be evaluated to determine if a more consistent methodcan be used.Element 15 -- Biosolids Management Program PerformanceReportProcess DescriptionThe performance report is a snapshot to date of the amount of biosolids produced,compliance performance, goals and objectives performance, summary of thecorrective actions and any audit results. This report is used to inform the public andother interested parties of major accomplishments or happenings concerning thebiosolids LGMS.Element Requirements (From the Guidance Manual)1. Complete a periodic written biosolids management program performancereport (at least annually), summarizing the performance of the biosolidsmanagement program. The report shall contain appropriate summaries ofmonitoring, measurements, and other results that demonstrate theperformance of the biosolids program relative to the organization’s goals,objectives, and legal requirements, including those biosolids managementactivities conducted by contractors. The report also shall providesummaries of performance relative to other voluntary adoptedReport Date: August 2, 2012 Page 25 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Resultsrequirements, the organization’s progress toward achieving its biosolidsprogram goals and objectives, and a summary of its independent, thirdpartyLGMS verification audit results.2. Make the periodic biosolids management program report available to thepublic. The organization shall have the flexibility of using other methods,including electronic methods such as a biosolids program webpage, inaddition to or in lieu of a written periodic performance report.1. Conforms.2. Conforms.Element 16 -- Internal LGMS AuditProcess DescriptionA procedure is in place for the Internal LGMS Audit and is followed during theinternal audits. The internal audit team develops a scope and plan for the audit andpresents it to the EMS Coordinator. Further development of questions and checklistswere reviewed during this audit period.Element Requirements (From the Guidance Manual)1. Establish and maintain an internal audit program to analyze the LGMS forbiosolids periodically and to determine whether it is effectively meeting itsbiosolids management policy, program requirements, and biosolidsprogram goals and objectives. The internal EMS audit program shalldefine the scope, frequency, and methodology of the audits, assignresponsibility for conducting the audits and communicating their findings,and designate individuals to whom these findings are to be conveyed. Theinternal audit also shall evaluate the organization’s performance relative toestablished biosolids program goals, objectives and performancemeasures. The internal LGMS audit program shall cover all theorganization’s biosolids management program activities, including thoseperformed by contractors.2. Report internal LGMS audit results to the organization’s management in amanner that allows them to take action to make necessary modifications tothe EMS and biosolids management program. The person responsible forthe biosolids management program shall develop, or delegate thedevelopment of, a comprehensive corrective action plan addressing eachnonconformance identified by the internal audit.Report Date: August 2, 2012 Page 26 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Results3. Maintain, at a minimum, the following documents and records, asapplicable, relating to the organization’s audit program:a) Description of audit methodology, protocol, scope, and scheduleb) Identification of lead auditor(s), qualifications, and description of rolesand responsibilities of auditors, management representatives, andothers that may participate in, review, or be expected to act upon the audit.c) Corrective and/or preventive action plans prepared resulting from anaudit, and any related changes made to policies, plans, procedures, andwork practices that occur as a result of an audit’s findings, evaluation, orfollow-up actions.1. Conforms.2. Conforms.3. Conforms.Element 17 -- Management ReviewProcess DescriptionA procedure is in place for the Management Review of entire LGMS procedures.The review is to be a general overview of what has occurred during the past year butspecifically to review adequacy, suitability, effective and overall performance.Element Requirements (From the Guidance Manual)1. At intervals the management determines appropriate, review the LGMSand its performance relative to policy commitments, goals, objectives, andestablished performance measures to ensure its continuing stability,adequacy, and effectiveness. The management review shall address thepossible need for changes to policy, the goals and objectives, the biosolidsmanagement program, and other LGMS Elements based on internal EMSaudit results, external verification LGMS audits by third parties, changingcircumstances, and the commitment to continual improvement. Themanagement review shall be documented. Any changes to policies, plans,procedures, and work practices that are made as a result of the review alsoshall be documented.2. Maintain, at a minimum, the following related to the organization’smanagement reviews:a) Schedule and scope for reviewb) Documentation of findings, evaluation, and follow-up actionReport Date: August 2, 2012 Page 27 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012Audit Resultsc) Documentation of changes to policies, plans, procedures, practicesand other LGMS Elements that occur as a result of the managementreview findings, evaluation, or follow-up actions3. Assign a lead person or persons to be responsible for organizing andconducting the review.1. Conforms.2. Conforms.3. Conforms.Report Date: August 2, 2012 Page 28 of 30


5. AppendicesLouisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012A. List of Requested ResourcesEMS Manual Revision 10National Biosolids Partnership National Manual of Good Practice forBiosolids, January 2005National Biosolids Partnership Management System Guidance Manual, June2002B. List of Reviewed DocumentsAppendix 3A, Critical Control Points Revision 14Appendix 5A, Goals and Objectives Revision 6Appendix 9A, Record of Public Input and Inquiries Revision 34Appendix 9B, Form for Public Input and Inquiries Revision 2Appendix 14A, Corrective/Preventative Action Plan Spreadsheet Revision 36Appendix 14B, Corrective Action Plan Form Revision 1Management Review Team Meeting Notes 3-2-12Management Review Team Meeting Notes 3-2-11Progress Toward Goals and Objectives 2-20-12Progress Toward Goals and Objectives 4-18-12Progress Toward Goals and Objectives 4-26-12Progress Toward Goals and Objectives 5-18-12Louisville Green Core Team Planning Notes 5-4-12Louisville Green Core Team Planning Notes 2-27-12Louisville Green Core Team Planning Notes 8-24-11Louisville Green Core Team Planning Notes 4-13-11Louisville Green Core Team Planning Notes 1-7-11Quality Assurance Process for Louisville Green Revision 9B-Shift Cleaning AssignmentsDryer Area Daily Cleaning AssignmentsSpecial Projects SpreadsheetMaintenance SpreadsheetReport Date: August 2, 2012 Page 29 of 30


Louisville Green Management System Audit ReportLouisville and Jefferson County MSDSubstituted Interim Audit #7 June 11-13, 2012C. Auditor QualificationsRobin Burch - Process Support Technician (Operations) Lead Auditor5 Years Quality Control Experience and 4 Years OperationsExperienceAdriane Neihoff - Environmental Response Pretreatment Inspector5 Years Pretreatment ExperienceJoe Falleri - Process Supervisor (MFWQTC Operations)21 Years Operations ExperienceJenni Schelling - Certified Internal Auditor (MSD Executive Offices)10 Years Internal Audit ExperienceReport Date: August 2, 2012 Page 30 of 30

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