Minimum Implementation Criteria

DOE-HDBK-1101-96

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 aug-

mented 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 promply

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.