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DOE-HDBK-1101-2004
Initially, the responses should be action plans indicating what corrective actions or additional
investigations will be done and when they will be completed. The document should be updated
periodically to indicate the completion of corrective actions.
Minimum Implementation Criteria
All elements of the PSM program must be evaluated for compliance with the PSM Rule every 3
years. DOE contractors must certify in writing that there has been a complete internal PSM audit
at least every 3 years. However, a complete audit need not be done all at one time. Rather,
various portions of a facility, such as process units or departments, may be audited at different
times, so long as a complete audit covering all elements is performed at least once every 3 years.
An effective internal audit should include a review of relevant documentation, an inspection of
the physical facilities, and interviews with all levels of plant personnel. (A sample audit format is
provided at the end of this section in Exhibit 2.13.) The internal audit must be conducted by a
team that includes at least one, and preferably several, persons knowledgeable in the processes
being audited. Such persons should understand the fundamental process hazards for the
operations being reviewed and should be familiar with the specific types of process units used.
The audit team should include a leader and members familiar with the process, experienced in
PSM, and trained in audit techniques. Team size should be a function of the number, size, and
complexity of the processes being audited. The internal audit team for any facility or process
may be either a "standing" audit team, an "ad hoc" team, or a combination, with some permanent
auditors augmented by different individuals for each audit.
Internal audits must detail the requirements of each element of the program being audited. A
properly designed checklist may assist the auditor in expediting the audit and to ensuring that no
requirements of the Rule are omitted. DOE contractors may adopt a sampling approach that
examines representative evidence of the PSM practices, such as drawings; training and
maintenance records; and results of personnel interviews. Contractors should develop their own
criteria for assessing the effectiveness of their PSM programs [Q90].
An audit report must be developed for each audit and the responsible facility manager must
promptly develop a response action plan for each finding. Such a response action plan may take
the form of an internal memorandum setting forth action items, responsibilities, and completion
targets. Action items and status may be tracked by computer to facilitate record keeping.
DOE contractors must further document that action items have been addressed and deficiencies
have been corrected. If a computerized database is used to track action items, a paper copy of the
documents that report completion of corrective actions should be maintained.
Contractor internal audit programs should provide a process to resolve worker or management
disagreements with audit findings. This process may refer issues to higher levels of management.
If a finding is reported for which management determines no action is necessary, the basis for the
management decision should be documented as part of the audit process. That is, the conclusion
that an audit finding is inappropriate or irrelevant may be an adequate response to a finding,
provided that the conclusion is well-founded and documented.
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