560 FW 7 Environmental Compliance Auditing Program	FWM#: 376 (Supersedes 560 FW 7, 12/31/96, FWM 309) Date: September 28, 2001 Series: Pollution Control Part 560:   Pollution at FWS Facilities Originating Office: Division of Engineering
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7.2 What are the program objectives? We engage in certain operations and activities that could cause environmental impacts on public health and the environment. The objectives of the Service Environmental Compliance Auditing Program are:

A. The establishment of Servicewide standards for environmental compliance audits as a means of ensuring our compliance with all applicable environmental laws and regulations.

B. Through the auditing process, assure the Director and environmental program managers that environmental programs are effectively addressing environmental problems that could:

(1) Impact Service mission effectiveness.

(2) Jeopardize the health of our personnel or the general public.

(3) Significantly degrade the environment.

(4) Expose the Service to avoidable financial liabilities as a result of noncompliance with environmental requirements.

(5) Erode public confidence in the Service and the Department of the Interior (DOI).

(6) Expose individuals to civil and criminal liability.

7.3 Who is responsible for the auditing program?

A. The Assistant Director, Business Management and Operations is responsible for the overall administration of the program.

B. The Chief, Division of Engineering provides guidance, funding, and support for the establishment, management, quality control, and implementation of the environmental compliance auditing program.

C. The Chief, Environmental and Facility Compliance Branch (EFC) is responsible for: 

(1) Establishment, management, quality control, Regional oversight, and implementation of the environmental compliance auditing program. 

(2) Audit training for Regional personnel and to certify that Regional personnel are capable of performing audits.

(3) Management of a national database for tracking audit findings.

D. Regional Directors are responsible for ensuring that facilities are in compliance with environmental laws and regulations and for the implementation of the auditing program in their Region.

E. The Regional Compliance Coordinators (RCC's), under the direction of the Regional Director, are responsible for planning and conducting audits within their respective Region. They are also responsible for the performance and tracking of the environmental auditing program that will utilize formal, informal, and self audits to accomplish its goals. The RCC's must maintain a list of all Regional facilities with an audit frequency for each facility.

F. Project Leaders/Facility Managers are responsible for ensuring environmental compliance at their facility and the correction of all negative audit findings through proposed corrective actions and requests for funding to remediate the situations. In addition, each manager will, on an annual basis or as findings are closed, provide the RCC an update of the status of all unresolved corrective actions.

7.4 What are the authorities for the Environmental Compliance Auditing Program?

A. 515 DM 2, Environmental Auditing.

B. Executive Order 13148, Greening the Government through Leadership in Environmental Management, April 21, 2000.

7.5 How is the program implemented? We will implement the program by conducting environmental compliance audits at Service facilities. Types of audits are:

A. Formal Audits. Formal audits require a site visit to the Service facility being evaluated. A team of two to three trained individuals will perform the audit. Onsite, the auditors will conduct record searches, interviews, and site surveys to determine the compliance status of a facility. Regional Compliance Coordinators take the lead on formal audits and, as required, receive oversight and assistance from the EFC. The EFC will visit each Region a minimum of one time per year on a formal audit to assure quality and consistency among the Regions. The formal audit process is divided into three phases:

(1) The RCC will send FWS Form 3-2137 (Environmental Compliance Questionnaire) to the facility manager approximately 60 days prior to the audit (see Appendix A in the Environmental Compliance Audit Handbook).

(2) The audit team completes the onsite audit using the Environmental Compliance Audit Handbook and State Supplements.

(3) The team provides a written report to the audited facility to document all findings. All formal audit results are then input into a national database.

B. Informal Audits. The RCC requests and documents informal audits. The facility manager conducts the actual on-the-ground audit using FWS Form 3-2138 (Informal Compliance Audit)(see Appendix B. Environmental Compliance Audit Handbook), the Environmental Compliance Audit Handbook, the State supplements, and with the support of Regional and EFC staff. Other Regional personnel may assist the facility manager as appropriate or necessary. Facility personnel will physically walk through their facility and address each applicable item in the questionnaire. This is a detailed, visual inspection of each building and associated facilities. The facility manager will document all findings and submit them to the RCC. The RCC will complete a report or memorandum to document the informal audit. All informal results will be input into the audit database.

C. Self Audits. Facility managers will use FWS Form 2139 (Self Audit Questionnaire) and will annually inspect their facility to determine compliance with environmental laws and regulations. The purpose of a self audit is to provide a quick evaluation of environmental issues during the period between formal and informal audits. We do not recommend that you conduct self audits during the same years when we will conduct a formal or informal audit.

7.6 How are compliance audit findings ranked or classified? Audit findings are ranked or classified as follows:

A. Significant. A significant deficiency requires immediate attention. It poses, or has a high likelihood to pose, a direct and immediate threat to human health, safety, the environment, or the facility's mission. The RCC's must immediately report significant findings to their Regional Director and the Division of Engineering.

B. Major. A major deficiency requires action, but not necessarily immediate action. Major deficiencies may pose a threat to human health, safety, or the environment. 

C. Minor. A minor deficiency is usually administrative in nature, even though those findings might result in a notice of violation. This category may also include temporary or occasional instances of noncompliance.

D. Required Practice: These findings are described as either positive or negative. These practices are not in violation of regulatory requirements, but must be corrected since they are Executive Orders, DOI policy, or Service policy.

E. Management Practice: These findings are described as either positive or negative. These practices are not in violation of regulatory requirements, but they can improve the operations of the facility.

7.7. How are compliance audits scheduled? Regional Compliance Coordinators will prepare an annual audit schedule that includes both formal and informal audits no later than August 1 of each year. RRC's will provide copies of the schedule to the Division of Engineering for funding allocation purposes and to assure consistency among the Regions.

7.8 What is the frequency of environmental compliance audits at Service facilities? The RRC's determine the frequency of audits according to the type and size of the facility. Some facilities must be audited more frequently than others. All facilities within a Region must be audited every 5 years or earlier. The frequency of each audit must be identified in the national auditing database. 

7.9 How are compliance findings documented and distributed?

A. The audit team must produce a Draft Findings Report within 30 days after the completion of the formal and informal audits in accordance with the following format. The reports will contain all environmental and safety-related findings associated with each audit:

(1) Section One. This contains an executive summary identifying where the audit was done, what was audited, and a list of the members of the audit team. It also provides background information on the site.

(2) Section Two. This section contains the objectives of the program.

(3) Section Three. This section contains the regulatory compliance findings that the audit team identified during the audit. An explanation of the finding ratings is provided, along with a compliance summary table, indicating the number of findings in each category. This section must contain all environmental and safety-related regulatory findings associated with each audit.

(4) Section Four. This section contains required practice (RP) findings that the audit team identified. These practices are not in violation of regulatory requirements, but must be corrected since they are Executive Orders, DOI policy, or Service policy.

(5) Section Five. This section contains the management practice (MP) findings. Management practice findings are described as either positive or negative. These practices are not in violation of regulatory requirements, but can improve the operations of the facility.

B. The audit team leader will distribute a copy of the Draft Findings Report to the facility, and the EFC will maintain a copy. Upon receipt of the report, the facility has 60 days to develop corrective actions for each of the regulatory, management practice, and required practice findings. A reply can be as simple as "situation corrected on June 30" or "work order request submitted on May 30, 2001, for construction of cement pad." If the facility has received a significant finding, the team leader will forward a copy of the report to the Regional Director. 

C. Upon receipt of corrective action replies, the audit team leader will issue a final report within 30 days. If a reply/corrective action is not appropriate to the finding, the audit team leader will contact the facility and resolve the issue. The audit team leader will make final distribution of copies to the Region, EFC, and the facility.

D. The RCC will participate in tracking the progress of corrective actions. The facility will submit a report to the Region 12 months after the finalization of the report detailing the status of corrective actions. All updates will be documented in the national database. Formal followups are required at every 12-month period after the initial audit until all corrective actions are completed. The RCC's will brief higher management and program managers annually on the status of audit findings and corrections.

7.10 How are environmental compliance findings tracked? The EFC will maintain a national database of all audits and their subsequent findings for all Service facilities. We will use this data to track the status of negative findings, to manage the auditing program, and to assist in formulating budget requests for corrective actions.

7.11 What is the Environmental Compliance Audit Handbook?

A. The EFC is responsible for the preparation and maintenance of the Federal and State supplements to the Environmental Compliance Audit Handbook. To establish consistency, the RCC's will use the Environmental Compliance Audit Handbook and the established standards for report writing.

B. The Handbook includes protocols for compliance with applicable environmental standards for use by auditors and facility managers in the performance of audits. The protocols are as follows:

(1) Air Emissions Management

(2) Drinking Water Management

(3) Hazardous Materials Management

(4) Hazardous Waste Management

(5) Pesticide Management

(6) Petroleum Oils, and Lubricants (POL) Management

(7) Solid Waste Management

(8) Special Pollutants Management

(9) Underground Storage Tank (UST) Management

(10) Wastewater Management

(11) Greening

7.12 What training opportunities are available for individuals involved in the program?

A. Conference calls between the EFC and the RCC's to evaluate program objectives, discuss any ongoing concerns, and table questions that may have arisen throughout the quarter.

B. Annually, members of the EFC and the RCC's meet for at least 1 day to discuss issues that will improve the auditing and compliance program.

C. Every 2 years or as the need arises, the EFC conducts an environmental auditing class. After this 1-week session, on-the-job training further enhances the abilities of the environmental auditors. The EFC certifies that Regional personnel are qualified auditors. Each trained auditor will receive a certificate.

7.13 What measures are taken to ensure quality control of the program?

A. Annually, EFC staff accompany each Region on at least one audit to evaluate their technical, organizational, and people skills. Documentation of these evaluations is accomplished on an FWS Quality Assurance Environmental Team Evaluation Form (FWS Form 3-2136).

B. The RCC's must request an evaluation from each facility being audited by using the FWS Quality Assurance Environmental Team Evaluation Facility Response (FWS Form 3-2135).

C. Annually, an outside evaluator (e.g., Corps of Engineers) will accompany Regional audit teams to at least one facility.

D. The EFC will continually monitor the auditing database to assure consistency and quality in report writing. This also reflects on the quality of the field audits.

E. The EFC will use quality assurance/quality control (QA/QC) to measure the effectiveness of the program by accumulating responses from the facility managers, self evaluations, and evaluations done by groups outside our bureau. Negative responses will be evaluated and acted upon to improve our procedures.

F. The EFC will maintain a file of the results of the QA/QC program and evaluated it to see if positive or negative trends are being established and if corrective actions are needed.

G. A critical part of our QA/QC program is the tracking of negative audit findings and the accomplishment of their corrective actions. The tracking of corrective actions monitors the commitment of facility managers and upper management to the program. The RCC's will annual brief upper management on the status of corrective actions.

H. After the baseline audits are accomplished, subsequent audits will reveal if repeat negative audit findings are occurring. Repeat audit findings can be due to neglect or lack of funding.