Interim Audit Report
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Interim Audit Report

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National Biosolids Partnership Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation Los Angeles, California Reverification Audit Audit Dates: August 11 - 14, 2008 Audit Conducted By: KEMA-Registered Quality, Inc. (Chalfont, PA) Auditors: Mr. Jon Shaver, Biosolids EMS Lead Auditor Mr. Michael Wardell, Biosolids Auditor Report Written By: Jon Shaver, Biosolids EMS Lead Auditor / Biosolids Auditor Report Date: October 8, 2008 Peer Reviewed By: Dale Scherger, Biosolids Auditor Approved By: Pierre Salle, KEMA-Registered Quality, Inc. Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 11 – 14, 2008 ________________________________________________________________________ Table of Contents 1. EXECUTIVE SUMMARY ....................................................................................................... 3 2. AUDIT DETAILS .................... 4 2A. Local Agency Details .. 4 2B. Audit Team ................................................................................................................. 4 2C. Audit Scope and Methodology .................... 4 2D. Reference Materials ................................................................................................... 5 2E. Definitions of Audit Findings & Required Corrective Action ........ 6 3. SUMMARY OF AUDIT RESULTS .......................... 7 3A. ...

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     National Biosolids Partnership Biosolids EMS Audit Report    City of Los Angeles Bureau of Sanitation Los Angeles, California    Reverification Audit      Audit Dates: August 11 - 14, 2008  Audit Conducted By: KEMA-Registered Quality, Inc. (Chalfont, PA) Auditors: Mr. Jon Shaver, Biosolids EMS Lead Auditor  Mr. Michael Wardell, Biosolids Auditor    Report Written By: Jon Shaver, Biosolids EMS Lead Auditor / Biosolids Auditor Report Date: October 8, 2008 Peer Reviewed By: Dale Scherger, Biosolids Auditor Approved By: Pierre Salle, KEMA-Registered Quality, Inc.   
 Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008  ________________________________________________________________________
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Table of Contents 1. CEXEVITUE  3SUMMARY ....................................................................................................... 2. AUDIT DETAILS .................................................................................................................... 4 2A. Local Agency Details.................................................................................................. 4 2B. Audit Team................................................................................................................. 4 2C. Audit Scope and Methodology.................................................................................... 4 2D. Reference Materials ................................................................................................... 5 2E. Definitions of Audit Findings & Required Corrective Action ........................................ 6 SUMMARY OF AUDIT RESULTS .......................................................................................... 7 3A. EMS Strengths ........................................................................................................... 7 3B. Outcomes................................................................................................................... 7 3C. Nonconformances ...................................................................................................... 7 3D. Opportunities for Improvement ................................................................................... 9 3E.  ................................................................................................ 9Verification Statement 3F.  9Appeals ...................................................................................................................... 3G. Agreements................................................................................................................ 9 AUDIT SNTAOISERVOB + RESULTS ................................................................................. 10 4A. Review of Open Nonconformances 10 .......................................................................... 4B. EMS Documentation Review.................................................................................... 10 4C. Audit - Biosolids Use & Disposition - Agriculture....................................................... 11 4D.  Use & Disposition - Composting..................................................... 11Audit Biosolids -4E. Audit - Communication Program .............................................................................. 11 4F. Audit - Competency, Awareness & Training Process ............................................... 12 4G. Audit - Compliance Process (with legal & other requirements) ................................. 12 4H. Audit - Contractor Control......................................................................................... 13 4I. Audit - Critical Control Points & Operational Controls (Identification)............................ 13 4J. Audit - Document Control & Recordkeeping Process ............................................... 14 4K.  ............................................................... 14Audit - Emergency Preparedness Process 4L.  ............................................................. 14Audit - EMS Planning & Public Participation 4M. Audit - Goals & Objectives Process.......................................................................... 15 4N. Audit - Internal Audits Process ................................................................................. 15 4O.  .......................Audit - Management Involvement (incl Policy, Management Review) 16 4P. Audit - Operations and Maintenance Processes....................................................... 16 4Q. Audit - Preventive and Corrective Action Process .................................................... 18 APPENDICES ................................................................................................................................. 19 Appendix 1  .......................................................................................... 19List of Participants Appendix 2 Documentation / Objective Evidence Reviewed .............................................. 21 Appendix 3  .......................................................... 22Desk Audit Findings (by EMS Element) 
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008  ________________________________________________________________________ 1. EXECUTIVE SUMMARY KEMA-Registered Quality Inc. (KEMA) conducted an independent audit of the environmental management system (EMS) being used by the City of Los Angeles Bureau of Sanitation (LA City) in managing its biosolids program. The audit was performed August 11 to 14, 2008 at the request of the National Biosolids Partnership (NBP) and wasa Reverification Audit, as required by LA City’s participation in the NBP’s Biosolids EMS Program. The purposes of this audit were to:  Verify that the management system being used by LA City in managing its biosolids activities meets the expectations and requirements of the National Biosolids Partnership’s Biosolids EMS Program, particularly the 17 EMS Elements (audit criteria)  Confirm that the LA City biosolids management program is functioning effectively and as intended, with practices and procedures being performed as documented.  Examine outcomes that LA City is achieving through the use of a systematic approach to managing their biosolids program.  The scope of this audit included the full LA City biosolids program, as defined in their Biosolids EMS Manual.  During the audit KEMA reviewed processes and activities used by LA City in managing its biosolids program and assessed the conformance of these processes with expectations and requirements of the National Biosolids Partnership EMS Elements.All “open” nonconformances from previous third party audits were closed. Five (5) new minor nonconformances were identified. Some additional minor nonconformances were corrected and closed within 3 weeks following this audit and are not included in the audit results. The unusual delay in submitting this report was a result of waiting for correction of those nonconformances.  In addition, KEMA identified strengths in the LA City biosolids management system and examined outcomes that LA City is achieving by using a management system approach in the areas of regulatory compliance, environmental performance, relations with interested parties and biosolids quality practices. These strengths and outcomes are detailed in the body of this report.  As a result of this audit, KEMA has verified that the biosolids management system being used by LA City meets the expectations and requirements of the NBP EMS Elements and we recommend continued certification of that management system within the National Biosolids Partnership EMS Program.   
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008  ________________________________________________________________________
 
2. AUDIT DETAILS 2A. Local Agency Details Agency Name, Location: City of Los Angeles Bureau of Sanitation, Los Angeles, California (referred to as LA City in this report) Biosolids Production Location(s): Hyperion Treatment Plant, Terminal Island Treatment Plant Number of Employees (approximate): 2800 Volume of Wastewater Treated (approximate): Hyperion Treatment Plant = 330 MGD  Terminal Island Treatment Plant = 29 MGD Tons of Biosolids Produced (approximate): Hyperion Treatment Plant = 650 wet tons per day  Terminal Island Treatment Plant = 50 wet tons per day  Biosolids Use / Disposition Sites Audited Green Acres FarmKern County CA Synagro Composting facility - Riverside, CA  Contractors Audited Solids Solutions (biosolids transportation and composting) RBM (biosolids transportation and land application)  2B. Audit Team The National Biosolids Partnership assigned KEMA-Registered Quality Inc. to perform this audit on their behalf. The KEMA Audit Team included Mr. Jon Shaver (Biosolids EMS Lead Auditor) and Mr. Michael Wardell (Biosolids Auditor). Both auditors are qualified for their roles through certification by the National Biosolids Partnership. KEMA asserts that our firm and auditors have an independent relationship with the City of Los Angeles Bureau of Sanitation that meets criteria established by the National Biosolids Partnership for Third Party Audit Companies and Auditors.  2C. Audit Scope and Methodology The scope of this audit included all parts of the LA City biosolids program, which encompasses pretreatment, biosolids stabilization, storage and transportation and end use / disposition, with special attention to practices and management activities that directly support biosolids-related operations, processes and activities.  The audit included the following topics, consistent with NBP requirements and the Scope of Work agreed by NBP and KEMA dated June 9, 2008. 1. Verification of open nonconformances from previous KEMA audits 2. Examination of outcomes being achieved in the areas of regulatory compliance, interested party relations, environmental performance and quality practices.
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008 ________________________________________________________________________  3. Process Audits (covering requirements of applicable EMS Elements and review of process effectiveness):  Biosolids Storage & Transportation  Biosolids Use & Disposition - Agriculture  Biosolids Use & Disposition - Composting  Communication Program  Competency, Awareness & Training  Compliance (with legal & other requirements)  Contractor Control  Critical Control Points & Operational Controls (Identification)  Document Control & Recordkeeping  Emergency Preparedness  EMS Planning & Public Participation  Engineering (incl process design)  EMS Documentation  Goals & Objectives  Internal Audits  iaM ecnanetn  Management Involvement (incl Policy, Mgmt Review)  erPaertnemtt  Preventive and Corrective Action  Solids Stabilization, Conditioning & Handling  Wastewater Treatment & Solids Generation  The audit was conducted by qualified auditors guidelines stated in the NBP Auditor Guidance (August 2007) and KEMA’s Biosolids EMS Audit Planning Guide.  Using sampling techniques, the auditor observed practices in place, interviewed key persons and reviewed pertinent documents and records to assess the systematic performance of the process being audited and the consistency of biosolids management practices with written procedures. Interested parties were interviewed and transaction tests were performed to verify the effectiveness of the management system. The audit was conducted as a systems audit and is not a verification of compliance with any legal requirements applicable to biosolids practices performed by the agency or its contractors.  2D. Reference Materials The following documents were used as references during this audit: LA City EMS Manual (current version) National Biosolids Partnership “EMS for Biosolids” standard (May2002) National Biosolids Partnership Biosolids EMS Third Party Auditor Guidance (August 2007) National Biosolids Partnership Code of Good Practice National Biosolids Partnership Manual of Good Practice  
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008 ________________________________________________________________________  
2E. Definitions of Audit Findings & Required Corrective Action Major Nonconformancea serious omission from requirements and/or other departure that represents, or could cause, a systemic failure. Major nonconformances must be corrected within 90 days for verification to proceed. Minor Nonconformancean isolated departure from requirements that does not represent a systemic failure. Minor nonconformances require timely and effective correction and verification by a Third Party Auditor. Opportunity (for improvement)possible improvement in the EMS based on auditor observations. There is no obligation for action in response to these observations.  
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008 ________________________________________________________________________  
3. SUMMARY OF AUDIT RESULTS 3A. EMS Strengths During this audit KEMA noted the following strengths in the LA City biosolids management system.  An active public outreach program is in place that has several benefits (e.g. Measure E, TIRE project)  Improved control methods at Green Acres have been introduced, including inspections, continuous surveillance  Use of biosolids at the Green Acres farm is well monitored  Positive feedback was received from all interested parties interviewed about LA City being honest and forthright about their biosolids practices  3B. Outcomes The LA City biosolids program is improving through the use of their management system. The following improvement outcomes within the past two years were confirmed.  Interested Party Relations  The effectiveness of LA City’spublic communication channels have improved as demonstrated by positive feedback received from Measure E and an increase in interested parties requesting information about the biosolids program  Quality Practices  Operations at both Hyperion and Terminal Island are now able to produce Class A biosolids consistently. In addition to improved product quality, this has provided significant cost benefit and suitability for additional uses.  Development of SOPs has improved operating practices and captured operator knowledge  Environmental Performance  The LA City pretreatment program & SIU inspections have contributed to a 20% reduction in Hg content in biosolids.  Regulatory Compliance  Continue 100% regulatory compliance with more stringent and demanding legal requirements, including local ordinances.  3C. Nonconformances During this audit, KEMA found five (5) minor nonconformances with respect to the audit criteria, as described below. Review of these nonconformances determined that they do not represent a
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008  ________________________________________________________________________
 
systemic deficiency. Additional comments made by LA City during their technical review of this report are noted.  Minor Nonconformance 08-03E / Element 5 NBP EMS Element 5 requires that biosolids objectives be measurable. Some biosolids (EMS) objectives in 2007-8 and 2008-9 are not stated in a way that allows the improvement to be measured.  Minor Nonconformance 08-04E / Element 5 NBP EMS Element 5 requires that action plans be developed for each biosolids objective. Action plans have not been developed for those biosolids (EMS) objectives that are not directly related to Division goals.  Minor Nonconformance 08-08E / Element 14 NBP EMS Element 14 requires that root cause be identified for nonconformances and LA City requires a responsible person be identified for taking corrective / preventive action. Corrective actions 07-01i, 02i, 04i and 05i do not fully identify root cause or clearly indicate the person(s) responsible for taking and verifying corrective action.  Minor Nonconformance 08-09E / Element 17 NBP EMS Element 17 requires that Management Reviews address performance relative to policy commitments and the continuing suitability, adequacy and effectiveness of the management system and LA City Element 6 requires that they address“public comments received” most recent management review (5/28/08) does not. The discuss public comments or performance against policy commitments or make any conclusion and/or recommendation about the suitability, adequacy and effectiveness of the management system.  Minor Nonconformance 08-12E / Element 10 LA City's definition of critical control points and operational controls (glossary) requires that they address "legal, quality and public acceptance requirements". The critical control points and operational controls and related monitoring and measurement identified by LA City (EMS Manual elements 3, 10 & 13, respectively) do not make a clear reference to legal, quality or public acceptance requirements.  Notethe above nonconformances is not sequential since otherthe numbering of nonconformances found were subsequently corrected following the audit and are not included in this report.  LA City has prepared corrective action plans for each nonconformance. KEMA’sLead Auditor has reviewed those plans and found them to be acceptable. The effectiveness of corrective actions taken will be verified during the next scheduled third party audit.  Additional Comments by LA City: “LA City corrected the nonconformances not included in this report. The nonconformances were related to documentation, i.e. clarifying language in the EMS manual and do not relate to operational controls of critical control points, regulatory requirements or contractor control and operations. The corrective actions to address the nonconformances were performed by the EMS Coordinator and approved by the Chief Operating Officer responsible for managing the City’s EMS.”  
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008 ________________________________________________________________________  3D. Opportunities for Improvement KEMA noted opportunities for improvement in the LA City biosolids program that are described in the“DetailedAudit Results” section of thisreport.  3E. Verification Statement Based on the results of this audit, KEMA has verified that the biosolids management system being used by the City of Los Angeles Bureau of Sanitation meets the expectations and requirements of the National Biosolids Partnership (NBP) Biosolids EMS Program. Continuing certification within the NBP Biosolids EMS Program is recommended.  3F. Appeals The NBP provides an appeals process for biosolids organizations and interested parties that disagree with the findings of a third party EMS audit. The verification appeals process involves an Appeals Board; representing a balance of biosolids management interested parties, including an environmental advocacy group, and wastewater industry professionals. An appeal must be submitted within 30 days of the official verification decision or interim audit decision by the Audit Company. Anyone who may need help in understanding the appeals process should contact the National Biosolids Partnership staff, Mr. Eugene DeMichele at 703-684-2438, or by e-mail: edemichele@wef.org.  An appeal process is available to persons concerned about the methods and/or scope of this audit. Further information about this appeal process can be obtained directly from KEMA (contact Pierre Salle, pierre.salle@kema.com or Jon Shaver jon.shaver@kema.com) or from NBP (contact Eugene DeMichele,le@wef.oedemichegr).  3G. Agreements LA City has developed written plans for correcting all nonconformances found during this audit. KEMA’s Lead Auditor has reviewed those corrective action plans and determined that effective implementation of the planned action will correct the respective nonconformances. LA City will implement the approved plans in a timely manner and review the corrections internally within 6 months. The effectiveness of actions taken to correct nonconformances will be verified during the next assigned third party audit. LA City and KEMA have agreed that interim audits of their Biosolids EMS will be conducted annually and that at least two of those audits will be Third Party Audits. The dates of the Third Party Audits are to be determined.  
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 Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008  ________________________________________________________________________
4. AUDIT OONSVATIBSER + RESULTS Observations and results of individual audits performed are described below. The National Biosolids Partnership Biosolids EMS Auditor Guidance (August 2007) and the KEMA Audit Planning Guide for Biosolids EMS Audits were used as guides in performing each audit  4A. Review of Open Nonconformances The auditor reviewed corrective action taken in response to the following nonconformances that remained open from the Verification Audit conducted by KEMA in August 2007.  Minor Nonconformance 06-01E The basis for determining priorities assigned to biosolids objectives is not defined. Corrective Action: Although not fully described in the EMS Manual, auditors verified that priorities are assigned on a subjective basis by the BAT. This nonconformance is now closed.  Minor Nonconformance 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. Corrective Action: The procedure in the EMS Manual has been modified to note that the Manual of Good Practice is “considered in developing critical control points and operational controls”. Auditors verified that persons who develop those controls understand and follow the procedure. This nonconformance is now closed.  Minor Nonconformance 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. Corrective Action: The Corrective Action Form being used by LA City has been modified to include results of the investigation and cause analysis and indicates whether the corrective action has been closed. This nonconformance is now closed.  Minor Nonconformance 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. Corrective Action: The internal audit performed by LA City July 30August 7, 2008 includes conclusions about the effectiveness of the communications process. This nonconformance is now closed.  4B. EMS Documentation Review LA City’s EMS Manual and supporting documents describe the management system being used in managing their biosolids activities. The manual is organized to correspond to the NBP EMS Elements and is available on the LA City website.The results of KEMA’s initial review of this documentation as part of this audit are included in the appendix of this report. Additional review
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Biosolids EMS Audit Report City of Los Angeles Bureau of Sanitation, Los Angeles CA Reverification Audit, August 1114, 2008  ________________________________________________________________________ during the onsite audit determined that the documentation satisfactorily meets NBP expectations and conforms to applicable requirements of the EMS Elements.  In addition, the following opportunities were noted:  The Biosolids EMS Manual could be simplified and shortened.  4C. Audit - Biosolids Use & Disposition - Agriculture Class A biosolids produced by LA City at each treatment plant are delivered to the Green Acres site in Kern County and land applied by RBM under contract with LA City. Biosolids are applied to land producing alfalfa, silage, Milo corn and Sudan grass. The operation is supervised daily by an on-site LA City site manager and inspected at least weekly by an LA City inspector. RBM and the site manager ensure correct agronomic rates are applied. Operational controls in place are consistent with LA City requirements, including documented plans / procedures and training. During this audit RBM demonstrated appropriate practices in unloading and applying biosolids at the site. Regulators interviewed are satisfied with performance at Green Acres and noted a quick response to a dust complaint in 2007. Operations at the Green Acres site were reviewed during this audit.  Audit Results The process described above was found to meet NBP expectations and conform to applicable requirements of the EMS Elements.  In addition, the following opportunities were noted:  Material Safety Data Sheets at the Green Acres farm could be reviewed / updated more frequently.  4D. Audit - Biosolids Use & Disposition - Composting Dewatered biosolids from LA City treatment plants are transported by vendors (contractors) to two use sites in California. Biosolids are processed into Class A Exceptional Quality products through composting at Synagro’s Riverside, CA Composting Facilities.Operations at the Riverside Composting site were reviewed during this audit. LA City owns and operates a composting facility at Griffith Park, however, this facility was not audited at this time due to time constraints.  Audit Results The process described above was found to meet NBP expectations and conform to applicable requirements of the EMS Elements.  4E. Audit - Communication Program LA City has an effective communications program in place for providing information to the public about biosolids and their biosolids program. E-mails are exchanged with a large and active interested party list and the website offers information and an interactive opportunity. Plant and farm tours are conducted. Brochures about biosolids are available. Participation in several community associations and the Integrated Resource Planning group enable opportunities for 2-way communication. A Biosolids Program Performance Report is issued annually and available on the
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