Compliance Assurance - Overview and Implementation Solutions - PowerPoint PPT Presentation

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Compliance Assurance - Overview and Implementation Solutions


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Title: Compliance Assurance - Overview and Implementation Solutions

Compliance Assurance- Overview and
Implementation Solutions
  • Air Waste Management Association
  • Southern Section Annual Conference
  • Callaway Gardens Lodge Spa
  • Pine Mountain, Georgia
  • August 3rd, 2011

Scott Kirby, Ph.D. Environmental Resources
What is Compliance Assurance?
  • Quantifiable measure of confidence that ALL
    regulatory requirements are being fulfilled and
    appropriately documented.
  • Drivers
  • Compliance Enforcement Actions
  • Civil and Criminal Penalties
  • Company Liability
  • Difficult to keep track of seemingly perpetual
    expansion of regulatory requirements, revisions
    and deadlines
  • Moving Target

Off-the-Shelf Software
  • Numerical-data gathering and reporting (task
  • Task-tracking has been viewed as the only way to
    exert real-time control of the compliance
  • Alerts sent out to task performers before due
    dates, and second tier alerts can invoke the
    chain of command for reinforcement if necessary.
  • Intent is to provide real-time feedback to
    management about the completion of tasks, and to
    spread out the task-completion documentation
    workload among the employees who perform the task.

Issues with Off-the-Shelf Software
  • Standardized format
  • Difficult to incorporate with company-specific
    policies and procedures
  • Requires constant updating as new and revised
    regulations are promulgated, and, as employees
    turnovers occur and
  • No option for feedback (Path of Least
  • Development of a check-box mentality.
  • Allows for the creation of a parallel universe
    where it appears as if events have been completed
    while the reality may be significantly different.

Parallel Universe Real World Example
  • EPA investigator asked to see records for the
    last two quarters of drain inspections required
    by the benzene waste NESHAP (40 CFR 61) at a
    petroleum refinery.
  • After reviewing the neat listing of drains that
    had been signed off on as Inspected, the
    investigator asked to look at the drains and the
    facility staff who performed the initialling was
    unable to locate about one third of the drains.

Opposite Parallel Universe
  • Conversely, the opposite of this is possible,
    where work is done but, for whatever reason (e.g.
    shift change), the electronic documentation in
    task-tracking system is not completed, or the
    inspection form is completed but not properly
    filed so it cannot be located during an agency

Perpendicular Universe
How Do We Get Back To The Real Universe
  • 2 Primary Approaches
  • Compliance Auditing
  • Periodic Checks

Compliance Auditing
  • Outside third-parties auditors
  • Number of requirements assessed is typically
    limited (time and knowledge)
  • Audit protocols merely restate the regulations,
    leaving the auditor to rely on his or her
    experience to devise a means of determining
    whether the facility complies.

Periodic Checks
  • Combines the looking-backward approach of a
    compliance audit with the periodicity of a task
    management process.
  • Typically does not entail significant work-habit
    changes since checks involve looking back at a
    number of actions at one time rather than
    time-consuming check-offs as each task is
  • Checks can be assigned to someone other than the
    original task performer, resulting in a
    check-and-balance system, but without the Big
    Brother feel that an audit may have.
  • Can easily accommodate multiple levels of

Periodic Checks - Concept
  • Checks are developed by taking the time to
    describe very specifically the records and
    documentation to be consulted and exactly how to
    check them against a specific requirement.
  • If written effectively, anyone familiar with a
    process or equipment should be able to perform
    the check and not just senior environmental
  • Since checks would be repeated on an ongoing
    basis, careful construction of task description
    can result in significantly more efficient
    performance over time
  • Allows for employee feed back
  • A wise southern gentleman once said There is
    more than one way to skin a cat!
  • Promotes a collaborative environmental between
    operations personnel and the red-headed
    step-children (A.K.A. HSE Staff)

  • Key stakeholders should define overall goals for
    the process.
  • All parties should buy in to process or else the
    your system versus our system labeling will
    undermine what might otherwise be a great idea
  • Due to complexity, typically new compliance
    assurance systems are implemented in phases.
    Phases should be planned based on a determination
    of depth of coverage.
  • Applicable requirements should be prioritized
    based on risk. Requirements deemed most
    important to the agency (as demonstrated by the
    greatest potential for agency-identified
    violations) should receive greater attention.
  • Industry and location-specific compliance issues
    should also be considered when assessing the risk
    associated with requirements.

Applicability Review
  • Applicability review should be transparent.
  • Not uncommon for facilities to reinvent the
    applicability determination each time someone new
    assumes responsibility for this function.
  • Create test for applicability at the rule level
    and then compile the test and the results of the
    test for each potentially applicable rule.
  • Ex. Applies to Chemical Plants
  • Further tests can then be compiled for individual
    citations such as does this tank store material
    with a vapor pressure equal to or greater than
    0.5 psia
  • This systematic approach to the applicability
    determination makes revisiting it a reading
    exercise instead of a re-creation exercise.
  • Not every applicable citation will result in a
    compliance obligation.
  • Some citations contain definitions,
    cross-references to other citations, or may be
    merely informational in nature.
  • These can be classified as does not contain a
    requirement and can be removed from the list
    requiring tasks or checks.

Developing Ongoing Checks
  • Process begins with looking at information that
    has already been compiled in the form of reports,
    procedures, and forms.
  • Matching these to specific regulatory citations
    forms the basis for developing the text of the
    ongoing checks.
  • This process reduces excess workload and
    identifies areas of potential improvement.
  • In our experience, fewer than 10 of existing
    requirements are covered by what is already in
    writing. Thus, it is important that interviews
    be conducted to gather information on how
    facility complies with most requirements.

Developing Ongoing Checks
  • Who (Personnel)
  • What (Task)
  • When (Frequency)
  • Where (Process and Documentation)
  • Why (Regulatory Requirement)
  • Where would you look, and what would you compare
    to what criteria to determine compliance?
  • Example Each quarter, review the periodic
    tank-seal inspection forms to ensure that each
    tank was inspected within 12 months of its last
    inspection (as indicated from by the date of the
    last form).

Development Guidelines
  • Assigned Responsible Position The person who
    has direct access to the data that will be
    assessed and either is responsible for the task
    to be checked or is a line or staff reviewer of
    that work.
  • Frequency Sufficiently often so that if there
    is a significant risk of a deviation, it would
    not run too long without discovery also consider
    whether specific deviations require any sort of
    prompt reporting
  • Clarity Checks should not be merely
    cut-and-paste from a regulatory requirement, but
    rather clearly describe the check in language
    that would be familiar to plant operations,
    maintenance, and other non-environmental staff
  • Completeness Checks should cover all main
    points in a requirement. Several independent
    checks may be needed for a single requirement.
  • References Checks based on a form or a
    procedure should clearly identify not just the
    document, but also the exact portion of it that
    addresses the requirement.

Functional Role Assignments
  • More efficient to assign these roles after the
    checks have been developed.
  • Following roles are typically involved
  • Unit Operations Foreman
  • Responsible for procedures that either contain
    the required operational practices and/or
    reference environmental procedures.
  • Unit Process Engineer
  • Responsible for equipment design parameters and
    operational data review.
  • Unit Environmental Staff Person
  • Performs checks that compare operational data
    between multiple sources, such as comparing
    vessel depressurizing reports to flaring logs to
    ensure that the proper records are being
  • Environmental Staff Rule Experts
  • Ensure that the environmental procedures cover
    the rule requirements, such as providing forms
    that request the proper information also,
    responsible for long-term record retention.

Rolling out the Periodic Check Process
  • Does not require special software and often times
    does not require a computer.
  • Does not require real-time completion logging but
    instead a cascade of sign-offs at specified times
    is conducted indicating the personnel are
    performing their duties.
  • Roll-out can be accomplished by unit, by task
    performing group, or by regulatory area.
  • Management of change process is essential to the
    success of a compliance assurance program.
    Regulatory information will need to be
    periodically updated as rules change, management
    goals change, and facility operations change.
  • Advantage of a periodic check system versus
    task-tracking software lies in the transparency
    of the MOC process.

  • Scott Kirby, Ph.D.
  • 820 University Boulevard South Suite 1A
  • Mobile, AL 36609
  • Email
  • Office (251) 380-0046
  • Mobile (251) 591-4451
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