Repeat Versus Recurring Findings in EHS AuditsMar 31st, 2012 | By Lawrence Cahill Robert Costello | Category: Auditing
Many organizations have been conducting environmental, health, and safety (EHS) audits for decades now, and as auditors revisit sites on a 2- or 3-year cycle, one of the most frustrating aspects of the audit outcomes is that many of the same or similar findings of noncompliance seem to arise time and time again. This situation is obviously troubling because it implies that site managers are not addressing the findings in a way that (1) results in permanent fixes and (2) truly changes the culture of the organization.
Hence, in order to minimize or even eliminate the occurrence of repeat findings, corporate management often puts in place a program of punitive measures or sanctions that are directed at site managers. This approach can be problematic for any number of reasons:
- It can change the tone of an audit program from independent and supportive to confrontational and combative. Site managers are never comfortable with repeat findings when a penalty might be incurred. The only possible exception is when the problem has persisted because of a lack of corporate or business unit funding for the necessary capital improvements.
- Perhaps more importantly, not everyone has the same idea about what is or is not a repeat finding. No consensus definition has been developed to help classify a finding as a repeat, which can cause serious disputes between site managers and the audit team. Moreover, where definitions have been developed, they are often not considered satisfactory to all concerned stakeholders. For example, in some audit programs, a repeat finding classification is given solely if the identical regulatory citation applies, regardless of whether the actual deficiency is precisely the same. In other audit programs, the technical deficiency must be almost identical to the one identified on the previous audit. In still other programs, classifying a finding as a repeat is basically at the auditor’s discretion.
This brief article focuses on the issue of defining repeat findings. (For more information on the role of repeat findings in evaluating audit program performance, please see Lawrence Cahill’s article Measuring the Success of an EHS Audit Program.) A “repeat finding” classification must be defined for an EHS audit program so that everyone is working from the same rule book. This will increase understanding across the board and hopefully minimize disputes.
Repeat findings are typically considered to be serious and justifiably receive significant management attention. However, before labeling something a “repeat,” auditors must focus on what actually caused the finding to occur. The question really is, did a breakdown in a management or control system cause this failure, or was it simply an isolated case of a similar nature? In other words—is this a repeat finding or a recurring finding?
What Is a Repeat Finding?
A repeat finding can be defined as one of the following:
- A finding that was identified in the previous independent audit for which a corrective action has not been completed as planned
- A finding that is substantially similar in nature to one that was identified in the previous independent audit
An example of an environmental audit finding that would clearly be considered a repeat would be the case of a site that on an initial audit is determined to be operating without a required air or wastewater permit and on the follow-up or subsequent audit still does not have the required permit. One factor that might color the repeat classification would be if the site had applied for a permit promptly but the issuing agency had not yet responded. The auditor would then have to decide whether the site’s follow-up efforts with the agency, over a 3-year period, were earnest and substantial (e.g., face-to-face meetings). If they were not, then there is a strong implication that the corrective actions were insufficient to correct the deficiency, and this could legitimately be called a repeat finding.
An example of a repeat safety finding would be a case such as the following: On the initial audit, a guard that protected workers from coming into contact with a high-speed belt was observed to have been removed from a major piece of rotating equipment. Operators claimed that the guard “got in the way.” After the audit, the site reported in its corrective action plan that the guard had been reinstalled. Three years later, on the next audit, the guard was once again found to have been removed. Another repeat finding.
What Is a Recurring Finding?
A finding that would probably not be considered a repeat finding is seen in the following example of an environmental audit of a wastewater treatment plant. Assume that 10 parameters (e.g., pH, BOD, and TSS) with daily effluent limits are listed in the discharge permit and that the audit review period is 3 years. This means that roughly 10,000 data points must be evaluated. Now assume that, on an initial audit, a small number of minor excursions of pH or BOD occurred over the 3-year audit period. Next, assume that on the subsequent audit 3 years later, it was determined that a small number of minor excursions of pH or BOD had occurred as well. Should the second set of excursions constitute a repeat finding if the management of the wastewater plant is otherwise found to be fundamentally sound? This is probably not a repeat finding, since wastewater treatment plants rarely operate in compliance with the permit limits 100 percent of the time.
A second example of a finding that might not be considered a repeat could be found on a fire safety audit at a large manufacturing site. Auditors, if they look long and hard enough, can almost always find an issue with inspections and maintenance of portable fire extinguishers. Should a missing tag on one fire extinguisher out of a universe of several hundred constitute a repeat finding if another extinguisher was without a tag on the previous audit? Again, if the management system is otherwise sound, the answer is “probably not.”
Similar situations can occur in other compliance areas where the universe of events or items to be audited is also quite large (e.g., material safety data sheets, hazardous waste manifests) and the likelihood of isolated failures is high. Auditors should think of these as recurring findings instead of repeat findings.
Identifying true repeat findings is a critical component of any EHS audit program, especially given that repeats can be interpreted as “willful and knowing” violations by regulatory agencies. However, there is a difference between “repeat” and “recurring” findings: repeat findings result from the breakdown of a management system or control, whereas recurring findings are mostly isolated occurrences that can happen in the best of programs. It is important for auditors to understand the difference between the two and ensure that sites are not punished or sanctioned by the repeat classification when the controlling system is otherwise fully implemented and effective.
Related Articles by Lawrence Cahill and Robert Costello
- Environmental Audits Versus Health and Safety Audits (Cahill and Costell0)
- Using Risk Factors to Determine EHS Audit Frequency (Cahill)
- Measuring the Success of an EHS Audit Program (Cahill)
- EHS Audits – Have We Lost Our Way? (Cahill)
- Statistically Representative Sampling on EH&S Audits: Expectations Established by Third Parties (Cahill)
- Outsourcing EHS Audits: Does it Make Sense? (Cahill)
- EHS Audits – Have We Lost Our Way? A Sequel (Cahill and Costello)
About the Authors
Lawrence B. Cahill, CPEA (Master Certification), is a Technical Director at Environmental Resources Management in Exton, Pennsylvania, U.S.A. He has more than 30 years of professional EHS experience with industry and consulting. He is the editor and principal author of the widely used text Environmental, Health and Safety Audits, which is published by Government Institutes, Inc. and is now in its ninth edition. He has published more than 60 articles and has been quoted in numerous publications, including The New York Times and The Wall Street Journal. Mr. Cahill has worked in more than 25 countries during his career. He holds a B.S. in Mechanical Engineering from Northeastern University, an M.S. in Environmental Health Engineering from Northwestern University, and an M.B.A. from the Wharton School of the University of Pennsylvania.
Robert J. Costello, PE, Esq., CPEA, is a Principal Consultant at Environmental Resources Management inExton, Pennsylvania, U.S.A. He has more than 17 years of professional environmental resource management and consulting experience. Mr. Costello manages global regulatory compliance, management systems, and sustainability assurance programs and typically participates on-site in 30 or more audits and assessments per year. He holds a B.S. in Environmental Engineering from Wilkes University, an M.S. in Environmental Engineering from Syracuse University, and a J.D. from Syracuse University. Mr. Costello is admitted to the bar in Pennsylvania, is a licensed professional engineer in Pennsylvania and Delaware, and is a Certified Professional Environmental Auditor.
Photograph: Spices 2 by Zsuzsanna Kilian, Budapest, Hungary.