2007 Final  Interim Audit Report-08-27-2007
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2007 Final Interim Audit Report-08-27-2007

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2007 Biosolids Environmental Management System (EMS) Interim Audit Report City of Los Angeles, Department of Public Works, Bureau of Sanitation Audit Report Date: August 27, 2007 Auditors: Thomas Ardent, Patricia Cruz, Diane G. Jones, Farhana Mohamed, Dipak R. Patel Audit Dates: July 30, 2007 to August 7, 2007 Report Author: Dipak R. Patel Approved by: Hiddo Netto for Traci Minamide Report Distribution List: Management Review Team Biosolids Action Team members Division EMS Representatives National Biosolids Partnership Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007 TABLE OF CONTENTS: 1. Summary………………………………………………………………………………4 1.1. Audit Scope and Methodology………………………………………………4 1.2. Summary of Audit Results…………………………………………………...5 1.3. Verification Statement……………………………………. …………………7 1.4. Agreements………………………………………………... ………………....7 1.5. Appeals…………………………………………………….. …………………8 2. Audit Details…………………………………………………………………………..8 2.1. Agency Details………………………………………………………………..8 2.2. Definitions of Terms & Closure Guidelines………………………………...9 2.3. Reference Materials…………………………………………………………..9 3. Audit Results………………………………………………………………………….10 3.1. Significant Changes…………………………………………………….……10 3.2. Summary of Results by EMS Element………………………………….....10 3.3. Status of Open nonconformances from Previous Audit………………….11 4. Detailed audit results…………………………………………………………………12 4.1. ...

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2007 Biosolids Environmental Management System (EMS) Interim Audit Report
  City of Los Angeles, Department of Public Works, Bureau of Sanitation
 Audit Report Date: August 27, 2007
 Auditors: Thomas Ardent, Patricia Cruz, Diane G. Jones, Farhana Mohamed, Dipak R. Patel  Audit Dates: July 30, 2007 to August 7, 2007  
 
Report Author:  Dipak R. Patel Approved by: Hiddo Netto for Traci Minamide
Report Distribution List: Management Review Team Biosolids Action Team members Division EMS Representatives National Biosolids Partnership
 
 
Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007
TABLE OF CONTENTS: 1. Summary4 1.1. Audit Scope and Methodology4 1.2. Summary of Audit Results...5 1.3. Verification Statement. 7 1.4. Agreements.......7 1.5. Appeals.. 8 2. Audit Details..8 2.1. Agency Details..8 2.2. Definitions of Terms & Closure Guidelines...9 2.3. Reference Materials..9 3. Audit Results.10 3.1. Significant Changes.10 3.2. Summary of Results by EMS Element.....10 3.3. Status of Open nonconformances from Previous Audit.11 4. Detailed audit results12 4.1. Examination of EMS outcomes..12 4.2. Review of EMS manual changes...13 4.3. Management involvement (including management review)..13 4.4. Audit-Biosolids Use and Disposition (Green Acres Farm).15 4.5. Audit-Corrective and Preventative Action Process.16 4.6. Audit-Maintenance Process17 4.7. Audit-Document Control and Recordkeeping Process...17 4.8. Audit-Emergency Preparedness Process.18 4.9. Audit-Roles and Responsibility Process.......19
2007 Biosolids EMS Interim audit report August 27, 2007
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Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007 4.9.1. EMS program..19 4.9.2. Training....19 4.9.3. Contractor20 4.10. Audit-Public Participation and Communication Process20 5. Appendices22 List of Audit Participants..22 List of Documents and Records Reviewed..23            
2007 Biosolids EMS Interim audit report August 27, 2007
Total number of pages in this report = 23  
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Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007
1 SUMMARY A five member team of auditors performed an audit of the City of Los Angeles (City) Environmental Management System (EMS) for biosolids. The audit was conducted July 30 to August 7, 2007. Audit process involved site visits, interviews, document verification, and inspection. The audit was performed to verify that the City of Los Angeless biosolids EMS conforms to the requirements of the National Biosolids Partnership (NBP) Environmental Management System for Biosolids, comprised of 17 EMS Elements. 1.1 Audit Scope and Methodology The City requested to substitute an internal audit for the interim audit and the request was approved by the NBP. The scope of the interim audit is consistent with NBP requirements for the biosolids EMS interim audit and the overall audit program agreed to by KEMA and the City. Reviews are performed to assess the overall program effectiveness of the EMS processes. Audits are conducted to verify conformance with NBP EMS requirements. The techniques used to conduct the audit are interviewing, observing, reviewing documents and records, and transaction testing. The scope included the following: 1. Review of corrective action process to address open nonconformances from previous audits (August 2006) 2. Examination of EMS outcomes (regulatory compliance, interested party relations, environmental performance, quality practices) 3. Review of ƒ  Significant EMS changes ƒ  EMS manual changes  Management Involvement ƒ  Management review process Goals and Objective Process   Corrective and Preventive Action Process  Communications process 4. Audit of ƒ Biosolids Use and Disposition-Green Acres Farm  ƒ  Corrective and Preventive Action Process Page 4 of 23 2007 Biosolids EMS Interim audit report August 27, 2007
Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007
ƒ  Maintenance Process ƒ  Document Control and Recordkeeping Process ƒ  Emergency Preparedness and Response ƒ  Roles and Responsibility Process ƒ  Public Participation and Communication Process 1.2 Summary of Audit Results EMS outcomes The Citys overall biosolids program is improving through the use of their EMS approach to managing this program. Recent outcomes are summarized below and detailed in Section 4 of this report.   The City continued its efforts to justify scientifically sound practice of land application ƒ at Green Acres resulting in Court decision to overturn the Kern County ban on biosolids.  ƒ  The process used to establish and track goals and objectives has improved the operations at Griffith Park Compost Facility by producing more compost and maintaining a record of no odors.  ƒ  The use of the Citys Communications Program has been effective in addressing and keeping the public informed about the Terminal Island Renewable Energy (TIRE) project.  ƒ  Increasingly positive feedback is being received from the public about the Bureaus biosolids communication efforts.  ƒ  Development of the Biosolids Strategic Plan by the City has assisted in investigating technologies/options and completing several concepts reports that would be used to help diversify the biosolids management program and reduce the amount of biosolids applied at Green Acres.  EMS strengths ƒ  The EMS manual is thorough. Each element is well-documented and tracked. ƒ  Terminal Island and Land Application Contractor document control and record keeping procedures/process are clearly defined and well documented. ƒ  Nonconformance procedure and corrective action process is documented and effective in addressing identified nonconformances.
Page 5 of 23 2007 Biosolids EMS Interim audit report August 27, 2007
Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007 ƒ  Communication methods established for responding to emergencies are well-defined. ƒ  Response plans for treatment plants are well-defined, clearly communicated, and effective in addressing a response. ƒ  Training Information Management System (TIMS) is an effective process for addressing and responding to training needs and record keeping. ƒ  Communication between regulator and the City is effective. The communication methods used by the City provide prompt response to regulators requests. ƒ  The Bureau Management and the EMS Coordinator are well aware of the policy, and the procedures for setting and tracking goals and objectives. ƒ  The management review process is well-defined and effective in providing directions to staff and addressing biosolids management issues. EMS weakness ƒ  EMS Manual that is located in Biosolids database (BEDRTS) is not easy to navigate and files are not easy to locate. ƒ  Staff and management being audited at Griffith Park Compost Facility regarding Emergency Response were not fully aware of documentation for the facility. EMS Nonconformances The 2007 internal audit found no major nonconformance and two (2) minor nonconformances. The minor nonconformances which were evident are described in Detail Audit Results section of this report. ƒ  07-03I Review of Response Plans for HTP and TITP are incomplete. Appendix A-Emergency supplies were not updated. (Element 11) ƒ  07-04I Emergency Action and Fire Prevention Plan for Griffith Park Compost Facility were not accessible and located at the facility . (Element 12) EMS Opportunities for Improvement The audit team identified several opportunities for improvement in the City of Los Angeless biosolids EMS. The opportunities are summarized below and are described in each applicable Detailed Audit Results section of this report. ƒ A guide could be provided to assist users in navigating through BEDRTS, especially  when trying to locate the EMS manual. For example, an index, search engine, or drop-down menu could be developed. (Elements 1 and 12)
2007 Biosolids EMS Interim audit report August 27, 2007
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Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007 ƒ  Establish a system to verify periodically that links to documents in BEDRTS are working properly. (Elements 1 and 12) ƒ  Include information about Terminal Island Renewable Energy project on the Biosolids EMS website (EMS Coordinator stated that this is being implemented). (Elements 6 and 9) ƒ  Place more information on the website related to farming operations, such as crop yields. (Element 9) ƒ  Develop a taskforce to focus on researching technologies/options appropriate to the City of Los Angeles to help diversify the biosolids management program. (Element 5) ƒ  Conduct more meetings with public and interested parties, i.e. quarterly to enhance public participation and outreach program. (Elements 6 and 9) ƒ  Perform more random periodic checks of contractor truck drivers to ensure that they have spill response plan, emergency equipment, etc. in truck. (Element 12) ƒ  Evaluate BEDRTS to improve accessing Standard Operating Procedures (SOPs), records, and evidence showing conformance with critical control points or cross-reference monthly Biosolids Program Management Report. (Element 12) ƒ  Provide periodic refresher training for treatment plant response coordinator. (Elements 8 and 11)  1.3 Verification Statement Based on the results and findings of this audit, the Bureau of Sanitation Audit Team has verified the management system for the Citys biosolids program continues to meet the expectations and requirements of the NBPs Biosolids EMS program. 1.4 Agreements The EMS Coordinator and other identified responsible divisions has agreed to prepare written plans for correcting the nonconformances identified during the audit. The responsible divisions will forward the plans to the EMS Coordinator by October 15, 2007. The plan should include action/tasks required, responsible  party, and expected completion date. The plans will be reviewed by the Management Review Team and if acceptable approved for implementation. The completion of actions taken to correct the nonconformances will be reviewed and discussed during the Biosolids Action Team meeting. The City will request that a third party auditor review all nonconformances identified during the 2006 audit and this audit to verify that the City has successfully completed all the interim audits following the original verification audit of the Citys program in August 2003. The City understands that in order to maintain its status as a certified NBP Page 7 of 23 2007 Biosolids EMS Interim audit report August 27, 2007
Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007 agency, the next audit in the sequence of audits required will be a re-verification audit conducted by an accredited third party auditor prior to September 4, 2008. 1.5 Appeals An appeal process has been developed by the NBP for use by biosolids organizations and interested parties that disagree with the findings of a third party EMS audit. An appeal must be submitted within 30 days of the verification decision by auditor. If you need help in understanding the appeals process you should contact the National Biosolids Partnership staff, Mr. Eugene DeMichele at (703) 684-2438 or send an email to edemichele@wef.org .  2 AUDIT DETAILS 2.1 Agency Details Organization: Department of Public Works, Bureau of Sanitation Address: 1149 S. Broadway Avenue, Los Angeles, CA 90013 Number Employees: 2800 (approximately) Wastewater Treated: Hyperion Treatment Plant- 360 million gallons per day Terminal Island Treatment Plant day -30 million gallons per day Biosolids Production: Hyperion Treatment Plant-72,000 dry tons per year (Exceptional Quality biosolids) Terminal Island Treatment Plant- 3,000 dry tons per year (Exceptional Quality biosolids) Biosolids Production Location(s): Hyperion Treatment Plant, Playa Del Rey, California Terminal Island Treatment Plant, San Pedro, California  Biosolids Use/Disposition Site Audited: Green Acres Farm (Kern County California)  Contractors Audited: Responsible Biosolids Management (RBM)  Interested Parties interviewed during audit (Telephone) Lauren Fondahl, U. S. EPA Region IX, Biosolids Coordinator Ed Deland, Member of Neighborhood Council Westchester/Playa del Rey
 2007 Biosolids EMS Interim audit report August 27, 2007
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Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007
Audit Team The Bureau of Sanitation selected an audit team from a pool of employees that are familiar with biosolids activities, EMS requirements, and completed biosolids EMS auditor training. The team members each have at least ten or more years of experience working for the Bureau of Sanitation. Mr. Dipak Patel, who is assigned to the Regulatory Affairs Division, is the lead auditor and author of the Interim Audit Report. (To see a profile of the audit team members, contact the Citys EMS coordinator at 310-648-5646 or derrick.k.lee@lacity.org. Audit Team Members:  Dipak Patel, Regulatory Affairs Division Patricia Cruz, Wastewater Engineering Services Division Farhana Mohamed, Environmental Monitoring Division Thomas Ardent, Hyperion Treatment Division-Operations Section Diane Gilbert Jones, Regulatory Affairs Division  2.2 Definition of Terms and Closure Guidelines During the audit findings are documented. Nonconformances and opportunities for improvements are identified. Corrective actions required to close nonconformances are outlined below.  Nonconformance: a nonconformance exists if a relevant EMS requirement has not been met or if repeated or numerous deficiencies exist for the same requirement. Major Nonconformance: a serious omission from requirements and/or other departure that represents, or could cause, a system failure. Major nonconformances must be corrected within 90 days for verification to proceed. Minor Nonconformance: an isolated departure from requirements that does not represent a system failure. Minor nonconformances require timely and effective correction and verification by the auditor. Opportunity for improvement: possible improvement in the EMS based on an auditor observation. Observations describe how the management system functions with respect to relevant requirements of the EMS. They can also identify opportunities for EMS improvement and/or highlight areas of strength within the EMS. There is no obligation for action in response to these observations.  2.3 Reference Materials The following documents were used as references during this audit: City of Los Angeles Biosolids EMS Manual (June 2007) City of Los Angeles Biosolids EMS Brochure (February 2005) Page 9 of 23 2007 Biosolids EMS Interim audit report August 27, 2007
Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007 City of Los Angeles Biosolids Policy Statement (December 2004) National Biosolids Partnership Biosolids EMS Interim Audit Report (Final)-City of Los Angeles, Bureau of Sanitation (October 2006) National Biosolids Partnership EMS Auditor Guidance (March 2006) National Biosolids Partnership Elements of an EMS for Biosolids (May 2002) National Biosolids Partnership Manual of Good Practice (Appendix F) 3 AUDIT RESULTS 3.1 Significant Changes No significant changes have been implemented for the Biosolids EMS since the last audit that was conducted in August 2006. 3.2 Summary of Results by EMS Elements The following table summaries the results of this audit as related to the seventeen (17) EMS elements. The elements that were fully audited during this audit are highlighted in bold. Nonconformances  EMS Element EMS 0S8t/a2t0u/0s 7()a s of (Includes nonconformances identified in August 2006 audit) 1. Documentation of EMS for Conforms None Biosolids  2. Biosolids Management Policy Conforms  None  3. Critical Control Points Conforms  None  4. Legal and Other Requirements Conforms  None  5. Goals and Objectives for Minor 06-01E The basis for determining priorities Continual Improvements nonconformance assigned to biosolids objectives is not defined. (Issued August 2006) 6. Public Participation in Conforms  None Planning  7. Roles and Responsibilities  Conforms   8. Training  
2007 Biosolids EMS Interim audit report August 27, 2007
Conforms  
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None  
None  
9. Communication  10 . Operational Control of Critical Control Points (Land application-Green Acres Farm  
11. Emergency Preparedness and Response  
12. EMS Documentation, Document Control and Recordkeeping  13. Monitoring and Measurement 14. Nonconformance: Preventative and Corrective Action  
15. Biosolids Program Periodic Performance Report 16. Internal EMS audit
Conforms  Minor nonconformance 
Minor nonconformance  
Minor nonconformance  Conforms  Minor Nonconformance 
Conforms
Minor nonconformance 
Conforms
Department of Public Works, Bureau of Sanitation Biosolids EMS Interim Audit #4 Report July 30-August 7, 2007 None  06-02E It is not clear how the development of operational controls considers best management practices, particularly the critical control points recommended in the National Manual of Good Practice. ( Issued August 2006)  07-03I Review of Response Plans for HTP and TITP are incomplete. Appendix A-Emergency supplies were not updated . (Issued August 2007)  07-04I Emergency Action and Fire Prevention Plan for Griffith Park Compost Facility were not accessible and located at the facility . (Issued August 2007)   06-03E The procedure for Nonconformance: Preventative & Corrective Action (El 14) does not reflect the actual practices used to identify need for corrections, investigate and determine causes and verify the effectiveness of action taken. (Issued August 2006)  None
06-04E The internal audit used as biosolids EMS Interim Audit 2 does not provide sufficient clear information about the effectiveness of the goals and objectives process or the communications program (Issued August 2006)   None
17.Periodic Management Review of Performance  3.3 Status of Open Nonconformances from Previous Audit The City has addressed and corrected all nonconformances identified during the August 2006 interim audit. A status report of the corrective action plan was forwarded to the third party auditor and the NBP in March 2007 . (Please contact the Citys EMS coordinator at 310-648-5646 or derrick.k.lee@lacity.org  if you would like to view the corrective action plan.)  The nonconformances were reviewed and corrective action process was audited during this audit. The City will request that the third party auditor Page 11 of 23 2007 Biosolids EMS Interim audit report August 27, 2007