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EMS Element 17. EMS Reviews

OOwner: EMS Coordinator
 Approver: EMS Core Team/EMS Management Review Team

Purpose/Overview

To define the process for conducting periodic audits of the Environmental Management System (EMS)  to verify the EMS conforms to planned arrangements and is properly implemented and maintained.

Definitions

  • audit - systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which the audit criteria are fulfilled
  • audit criteria - set of policies, procedures or requirements against which audit evidence is compared
  • audit evidence - records, statements of fact or other information which are relevant to the audit criteria
  • audit findings - results of the evaluation of the collected audit evidence against audit criteria; audit findings can indicate either conformity or nonconformity with audit criteria or opportunities for improvement
  • audit program - set of one or more audits planned for a specific time frame and directed towards a specific purpose; an audit program includes all activities necessary for planning, organizing and conducting the audits
  • audit plan - description of the activities and arrangements for an audit
  • audit scope - extent and boundaries of an audit; the audit scope generally includes a description of the physical locations, installation units, activities and processes, as well as the time period covered

USMC EMS Conformance Criteria

The USMC EMS Conformance Guide, dated Dec 2004, establishes conformance requirements for each element of the Marine Corps EMS. The following EMS conformance criteria are applicable to Element 17, EMS Reviews, of the MCAS Miramar EMS:
  • The installation evaluates its EMS against the criteria listed here at intervals appropriate to the size of the installation.
  • The installation supports the Headquarters, Marine Corp EMS Review conducted as part of the HQMC ECE every three years.

MCAS Miramar EMS Procedure/Process Description

1. General overview of the audit program

1.1 Frequency and scope of audits - Audits are performed at a frequency determined to be appropriate by the EMS Coordinator. At a minimum each EMS core element will be audited at least once per year. The Schedule of Past and Planned Audits summarizes the audit schedule, the general scope of audits and audit results/reports.

 The scope and frequency of audits are determined based on consideration of the following:

  • the importance of activities
  • the results of previous audits
  • the results of management reviews
  • the base's performance versus established EMS objectives and targets

1.2 Staffing of audit teams - The base strives to develop audit teams that possess the overall expertise and skills needed to conduct EMS audits that provide sufficient benefit to the EMS. When selecting EMS auditors, consideration is given to the following criteria:

  • Competence - auditors should possess the appropriate combination of knowledge, skills and experience to perform audit responsibilities
  • Objectivity - auditors should be independent of the activities they audit; they should be free from bias and conflict of interest throughout the audit process

All audits are conducted by appropriately trained and qualified auditors, as described in the STRUCTURE AND RESPONSIBILITY and TRAINING EMS elements.

The base may elect to use internal or external resources, or a combination of both, to conduct EMS audits. Audit teams may consist of one or more trained, qualified auditors. A Lead Auditor is designated for all EMS audits.

1.3 Due professional care and confidentiality - Auditors should use a level of care, diligence, and judgment expected of any auditor in similar circumstances while conducting a EMS audit. Unless required by law, EMS auditors are not permitted to disclose information or documents obtained during or after the audit, including the audit report, to any third party without written approval of the EMS Core Team.

2. The audit process - EMS audit activities are performed in a three-stage process that includes: preparation, evaluation and reporting. Each of the stages of the base's EMS audit process are described below.

2.1 Audit preparation - The EMS Coordinator and the designated Lead Auditor collaborate to complete an Audit Plan prior to each EMS audit (view September 2007 Internal Audit Plan and Summary Report). The Audit Plan establishes audit objectives, scope, criteria, staffing, reporting requirements, etc.

The Lead Auditor notifies personnel who will be affected by the audit (including audit team members and those being audited) within a reasonable time period prior to the audit.

The Lead Auditor prepares the audit team to conduct the audit. This includes providing audit team members with the audit plan, audit assignments and relevant supporting documentation (e.g., protocols, checklists, procedures, previous audit reports, etc.). The Lead Auditor also consults with audit team members prior to the audit to verify that they have reviewed the necessary audit information and clearly understand their audit assignments.

Each auditor is responsible for reviewing the documentation that is provided to them by the Lead Auditor to develop an understanding of the objectives and scope of the audit and the nature of the installation's EMS.

2.2 Evaluation of the EMS - The overall objective of the audit program is to evaluate the installation's existing EMS against the USMC EMS Conformance Guide and against the installation's documentation describing that system. This objective is accomplished by the audit team's evaluation of the implementation and effectiveness of the EMS. The following activities are performed during the evaluation phase of the audit:

  • Opening meeting - The Audit Team holds a brief opening meeting with affected installation personnel to review the scope, plan and schedule for the audit.
  • Evaluation/audit activities - Using their audit protocol checklists as guides and conducting interviews with appropriate installation personnel, the audit team separates and gathers objective evidence (e.g., controlled documents, records and confirmed statements) to verify conformance to EMS requirements. Activities may include: interviews with installation personnel, review of pertinent records, observation of activities and processes, etc. Auditors must maintain notes of audit activities so that nonconformance items/audit findings can be effectively described during the reporting phase of the audit.
  • Closing meeting - The audit team holds a closing meeting with affected personnel to review the preliminary findings of the audit and clarify any open or inaccurate items.

2.3 Reporting - The Lead Auditor directs the following reporting efforts:

  • Documentation of nonconformance items/audit findings - Each auditor records detailed audit findings based on the results of their audit activities.
  • Audit summary report - The audit team prepares a written audit report and provides the report to the EMS Coordinator within an acceptable time frame. This report may be a 'stand-alone' report, or it may be incorporated into the Audit Plan and Summary Report. The audit summary report should: summarize the audit scope (with an emphasis on any changes made to the planned scope of the audit); describe sources of objective evidence used; describe the overall results of the audit; and provide the installation with direction for corrective actions and improvements. EMS Self-Audit is conducted annually beginning in Sept. 2005.  Annual EMS audit reports are as follows:
  • 2005 Self-Audit
  • 2006 Self-Audit
  • 2007 Self-Audit
  • 2007 POA&M to Draft EMS Audit Report
  • Marine Corps Acknowledgment to MCAS Miramar EMS Program
  • 2008  Self-Audit Plans of Actions and Milestones
     

3. Audit follow-up and corrective action - Audit findings that require corrective action are managed in accordance with the PROBLEM SOLVING EMS element. It is the responsibility of the personnel being audited, not the audit team members, to handle correction action associated with audit findings.

Audit reports, including audit findings and the results of related corrective action, are reviewed by the installation's Environmental Leadership Council while performing MANAGEMENT REVIEW.

4. Review by EMS Management Review Team  - The EMS Management Review Team of  MCAS Miramar reviewed the  EMS program developed by the EMS Core Team.  The EMS Management Review Team determined that the program is aligned with the HQMC Conformance Guide and has met the deadlines for implementation December 31, 2005 and full conformance December 31, 2007.

References and Related EMS Documents
USMC EMS Conformance Guide Dec 04

Document Revision History

Revision Date Nature of Revision Document Review Participants
12/13/2006 Update content EMS Core Team
9/20/07 Update content EMS Core Team
12/19/07 Update content EMS Core Team
11/17/08 Update content EMS Core Team

 


Management System documents are maintained as described in the DOCUMENT CONTROL Procedure. Printed documents are UNCONTROLLED.