Office of Inspector General

Audit Report

Follow-up Audit

Environmental, Safety, and Health Issues

at EPA Laboratories

E1DMD8-11-0002-8100185

July 23, 1998 
Inspector General Division(s)

 Conducting the Audit

Headquarters Audit Division

 Washington, DC

Region(s) covered Headquarters

Program Office(s) Involved Office of Administration and Resources

 Management: Safety, Health and 

 Environmental Management Division

Office of Research and Development:

 Office of Resources Management and

 Administration

Office of Enforcement and Compliance

 Assurance: Federal Facilities Enforcement

 Office
MEMORANDUM

SUBJECT: Follow-up Audit of Environmental, Safety, and Health Issues 

 at EPA Laboratories

Audit Report No. E1DMD8-11-0002-8100185

FROM: Michael Simmons

Deputy Assistant Inspector General for Internal Audits 

TO: Alvin M. Pesachowitz

Acting Assistant Administrator

 for Administration and Resources Management

Attached is our final report on “Follow-up Audit of Environmental, Safety, and Health

Issues at EPA Laboratories.” A draft of this report was issued to you on May 19, 1998, and

comments were received from your office on July 10, 1998. The comments provided describe the

specific actions along with the milestone dates for completion in accordance with EPA Order

2750. Therefore, we are closing the report in our Prime Audit Tracking System upon issuance. 

This report describes findings and corrective actions the Office of Inspector General

(OIG) recommends to improve and strengthen EPA’s environmental, safety and health (ESH)

program. We found that the Agency had implemented many recommendations from our 1995

report. However, we identified areas of concern that required additional improvements. The

report provides recommendations to address these concerns. It represents the opinion of the

OIG. Final determinations on matters in the report will be made by EPA managers in accordance

with established EPA audit resolution procedures. Accordingly, the findings described in this

report do not necessarily represent the final EPA position and are not binding upon EPA in any

enforcement proceedings brought by EPA or Department of Justice.

We appreciate your response to our draft report and its recommendations. Actions that

the Safety, Health, and Environmental Management Division have already initiated will further

enhance EPA’s ESH program. Should you or your staff have any questions, please contact

Norman E. Roth, Divisional Inspector General for Audit, Headquarters Audit Division on

(202)260-5113.

Attachment

Report No. 8100185

EXECUTIVE SUMMARY

INTRODUCTION

On September 27, 1995, the Office of the Inspector General (OIG) issued a report,

“Environmental, Safety, and Health Issues at EPA Laboratories.” A follow-up audit was initiated

to determine if the Agency had implemented the recommendations provided in that report. Since

most of the recommendations were directed at Agency Headquarters, we limited our audit to

Headquarters offices and did not revisit any laboratories. We focused on available

documentation, to the extent possible, to evaluate progress. We interviewed personnel in the

Office of Administration and Resources Management (OARM) and Office of Research and

Development (ORD). This follow-up audit was conducted from December 1997 through March

1998. 

Environmental Protection Agency (EPA) personnel perform operations in laboratories and

during field inspections which subject the Agency to the very environmental regulations that it is

responsible for promulgating and enforcing. Safety and health programs are also applicable. The

1995 OIG report included recommendations for improvements to EPA’s ESH program and audit

process. Agency management agreed to implement the recommendations or take other actions to

address the issues. 

After the release of the OIG report, the Agency issued the Code of Environmental

Management Principles for Federal Agencies (CEMP) in 1996. This code, which emphasizes

pollution prevention and sustainable development, is applicable to the Agency’s ESH operations. 

It focuses federal agencies on the necessity of state-of-the-art environmental management for

reaching the highest levels of environmental performance. CEMP relates closely to our 1995

report recommendation that EPA establish a model environmental program which could also

address safety and health issues. 
ii Report No. 8100185

OBJECTIVES

The objectives of the follow-up audit were: 

• to determine if Agency management has implemented corrective actions indicated in their

response to the 1995 OIG report and, 

• to assess the Agency’s status in implementing CEMP as established for federal agencies.

RESULTS IN BRIEF

The Agency implemented most of the corrective actions addressed in our 1995 OIG

report. However, improvements could be made in the evaluation of EPA’s ESH personnel and in

the Agency’s ESH audit process and reporting requirements. Also, we recommended in our prior

report that EPA develop a model program to serve as a standard for environmental management. 

EPA has not fully implemented CEMP requirements, which would generally meet the intent of

our recommendation. In its role as a leader both nationally and internationally in environmental

programs, EPA should establish a standard for excellence in implementing responsible

environmental management at its own laboratory and facility operations. 

RECOMMENDATIONS 

We recommend that the Acting Assistant Administrator for Administration and Resources

Management: 

• Strengthen ESH audit protocol to address training and qualifications of ESH personnel to

best complement the individual laboratories’ ESH needs.

• Further enhance the ESH audit process for risk assessment and access to audit corrective

action tracking systems. 

• Fully implement CEMP, challenging the Agency to move forward to a higher level of

environmental management and provide leadership not only for federal, but also national,

ESH programs.
iii Report No. 8100185

Agency Response & OIG Evaluation

The Office of Administration and Resources Management generally agreed with each of

the recommendations in the draft report and provided planned corrective actions as well as

milestone dates for completion. The specific corrective actions planned are included after each

chapters’ recommendations and the response is included in its entirety as Appendix II.

We believe the corrective actions underway and planned by the Agency address the

report’s recommendations, therefore, we are closing this report upon issuance. No further

response by the Agency is necessary. 
Report No. 8100185
iv Report No. 8100185

TABLE OF CONTENTS

Page

Executive Summary .......................................................... i

Abbreviations .............................................................. v

Chapter 1 ................................................................. 1

Introduction .......................................................... 1

Purpose ....................................................... 1

Background .................................................... 1

Scope and Methodology ........................................... 2

Prior Audit Coverage ............................................. 2

Chapter 2 ................................................................. 3

EPA’s Implementation of Corrective Actions to Improve Its ESH Program .......... 3

Conclusion .................................................... 12

Recommendations .............................................. 13

Chapter 3 ................................................................ 17

EPA’S Implementation of CEMP ......................................... 17

Conclusion ................................................... 20

Recommendations .............................................. 20

Appendices:

Appendix I. Results of 1995 Audit ....................................... 23

Appendix II. Agency Response .......................................... 27

Appendix III. Distribution of Report ...................................... 33
v Report No. 8100185

ABBREVIATIONS

CEMP Code of Environmental Management Principles for Federal Agencies

EPA Environmental Protection Agency

EMR Environmental Management Review

ERL Gulf Breeze- Environmental Research Laboratory Gulf Breeze, Florida

ESH Environmental, Safety and Health

OARM Office of Administration and Resources Management

OIG Office of Inspector General

ORD Office of Research and Development

RCRA Resource Conservation and Recovery Act

RTP Research Triangle Park

SHEMD Safety, Health, and Environmental Management Division

SHEMP Safety, Health, and Environmental Management Program

SHEMPMGRs Safety, Health, and Environmental Management Program Managers
1 Report No. 8100185

CHAPTER 1

Introduction

Purpose On September 27, 1995, the Office of the Inspector

General (OIG) issued a report, “Environmental, Safety, and

Health Issues at EPA Laboratories.” The report included

recommendations for improvements in the Agency’s

environmental, safety, and health (ESH) program and audit

protocol. Agency management agreed to implement the

recommendations or take other actions to address the

issues. The objectives of the follow-up audit were to:

• determine if Agency management has implemented

corrective actions indicated in their response to the

report and, 

• assess the Agency’s status in implementing the Code

of Environmental Principles (CEMP) established for

federal agencies.

Background Environmental Protection Agency (EPA) personnel

perform many of the same functions that are subject to the

very environmental regulations that the Agency is

responsible for promulgating and enforcing. These

regulations include liability for sanctions covered under the

Federal Facilities Compliance Act. The Agency is

responsible for maintaining internal safety and health

programs under Part 19 of the Occupational Safety and

Health Act of 1970 and Executive Order 12196,

Occupational Safety and Health Programs for Federal

Employees, dated February 26, 1980. In addition,

Executive Order 12856, Federal Compliance with Right-toKnow Laws and Pollution Prevention Requirements,

required the Agency to establish a voluntary “Federal

Government Environmental Challenge Program” including a

code of environmental management principles.
2 Report No. 8100185

Since the completion of the 1995 OIG report, the

Agency issued the Code of Environmental Management

Principles for Federal Agencies (CEMP) on October 16,

1996. This code is closely related to the OIG report

recommendation that EPA establish a model environmental

program (which could also address safety and health issues). 

This model program would assist management by providing

an overview of the ESH program and supplement the

Agency’s ESH audit protocol.

Scope and Methodology The follow-up audit was performed in accordance

with the Generally Accepted Government Auditing

Standards (Government Auditing Standards, 1994

Revision). Audit work was conducted from December

1997 through March 1998. We focused on available

documentation, to the extent possible, to evaluate progress. 

In addition, we interviewed personnel in the Office of

Administration (OARM), including SHEMD, and in the

Office of Research and Development (ORD). We talked to

Federal Facilities Enforcement Office personnel in the Office

of Enforcement and Compliance Assurance for information

related to the CEMP. We reviewed SHEMD policy and

procedure documents and audit reports. Since most of the

recommendations from the previous review were directed at

Headquarters, we limited our review to Headquarters

offices and did not revisit field activities. This audit was a

short-term study of EPA activities, performed to determine

progress in correcting previously identified issues. 

Prior Audit Coverage Recommendations from the September 27, 1995

OIG audit report, “Environmental, Safety, and Health Issues

at EPA Laboratories,” are provided in Appendix I.

No additional OIG reports have been issued directly

related to EPA’s Environmental, Safety, and Health

program. 
3 Report No. 8100185

CHAPTER 2

EPA’S IMPLEMENTATION OF CORRECTIVE ACTIONS 

TO IMPROVE ITS ESH PROGRAM

In our 1995 audit, we found that, although EPA’s

ESH Program for laboratories was improving, it was

inadequate overall. We evaluated the ESH programs at five

laboratories, reviewing the performance of ten critical ESH

program elements such as environmental program support,

management support, and building and fire safety. These

elements were rated as model, adequate, or inadequate. All

facilities were rated inadequate in at least two of the ten

critical elements. One laboratory (Gulf Breeze) was rated

inadequate in nine of ten elements. We believed that an

inadequate rating in even one element left the facility

vulnerable. We also found that OARM needed to improve

the ESH audit process and its visibility to management. 

Concerns included: use of contractors to perform the

audits; less than timely release of draft and final reports; and

inadequate consideration of laboratory responses to issues

addressed in the draft reports. Our recommendations in the

1995 report and the actions the Agency has taken are

addressed in the following sections.

Declare EPA’s ESH

Programs an Agency-Level

Weakness During the 1995

Integrity Act Process.

ORD identified its ESH program as a material

weakness in its Integrity Act reports since 1992. However,

our 1995 audit confirmed that program inadequacies were

not confined to only ORD laboratories. We observed no

major differences in the implementation of the ESH

program in either ORD or Regional laboratories. 

Furthermore, SHEMD's audits were performed in the same

manner at Regional and program office laboratories, and the

types and number of findings were similar. 

Based on our recommendation, EPA declared

“Safety, Health, and Environmental Management Issues at

EPA Laboratories” as an Agency-level weakness in the

1995 Integrity Act report. The corrective actions, which

were to be completed in fiscals 1996 and 1997, included
4 Report No. 8100185

directing senior managers to take personal management

responsibility for their ESH programs, committing adequate

resources to manage their programs, correcting all

outstanding weaknesses, and conducting self evaluations. 

OARM, specifically SHEMD, was accountable for

monitoring the progress of laboratories in enhancing their

respective programs. SHEMD also was responsible for

enhancing its audit protocol for selecting facilities to audit;

upgrading its automated follow-up process to better track

corrective actions; and providing senior managers periodic

assessments of individual facility ESH programs and

reminders of all open findings. Result indicators included

improvements in laboratory managers’ periodic selfassessments, corroborated by fewer Headquarters’ ESH

audit deficiencies and quicker resolution of outstanding

findings. At the end of fiscal year 1997, the Agency

reported that all corrective actions had been completed and

the Agency-level weakness was resolved.

We believe that the Agency has taken adequate

action to address the OIG requirements for this

recommendation. No further action is required. 

Require OARM To Develop

a Model Environmental

Program Which Also 

Addresses Occupational

Safety and Health

Requirements.

For several years, many EPA managers have

identified weaknesses in the Agency's ESH program and

recognized that the Agency needs to do more to strengthen

it. Laboratory managers and ESH personnel generally

supported the concept that the Agency should have more

than just an adequate ESH program. Given that EPA has

created the environmental regulations and enforces

compliance at federal and private laboratories, EPA should

set the standard for excellence at its own laboratories. In

fact, Executive Order 12856 states that, “. . . the Federal

Government should become a leader in the field of pollution

prevention through management of its facilities, its

acquisition practices, and in supporting the development of

innovative pollution prevention programs and

technologies.” Although EPA has made progress in ESH

program improvements, some laboratory personnel, who

were not directly responsible for ESH programs, resisted

being held responsible for any requirements beyond
5 Report No. 8100185

regulatory requirements. The 1995 OIG report

recommended that the Agency clarify its ESH program

goals in order to formally define a model ESH program

based on the inadequacies identified at five EPA

laboratories. 

Subsequent to our report, EPA’s Office of

Enforcement and Compliance Assurance issued CEMP,

which closely relates to our recommendation for a model

program. Therefore, we assessed the Agency’s progress in

meeting CEMP. The assessment is discussed in Chapter 3

of this report. 

Instruct ORD and OARM

to Take Immediate Action

to Reduce ESH Risks at

ERL Gulf Breeze.

Of the five facilities we reviewed in the 1995 audit,

Environmental Research Laboratory (ERL) Gulf Breeze had

the weakest ESH program. The facility experienced two

fires and was cited for a Resource Conservation and

Recovery Act (RCRA) violation. We also found another

RCRA violation during the OIG on-site visit. The

conditions at ERL Gulf Breeze jeopardized the health and

safety of EPA employees and possibly that of the nearby

residential community as well. We recommended that ORD

and OARM take immediate action to reduce ESH risks at

ERL Gulf Breeze and document completed actions. The

Agency agreed to monitor and keep management apprised

of progress.

In May 1997, SHEMD completed an audit of

National Health and Environmental Effects Research

Laboratory, Gulf Ecology Division, Gulf Breeze (formerly

ERL Gulf Breeze). The report noted a dramatic decrease in

the overall number and severity of environmental, safety and

health, and fire findings since the 1994 audit. In addition,

we reviewed documentation of corrective actions at Gulf

Breeze. This document indicated that SHEMD and ORD

assisted Gulf Breeze’s program by completing a

comprehensive inventory of all hazardous chemicals and

constructing an automated chemical management system. 

Finally, SHEMD’s corrective action data base showed that

Gulf Breeze had closed out several of the findings from

SHEMD’s 1997 audit and were addressing the remaining

findings. According to the SHEMD in-house auditor, a new
6 Report No. 8100185

director had been assigned to Gulf Breeze after the 1994

audit and the director was more involved with the ESH

audit issues. This auditor noted that the laboratory has

turned around and is now in “great shape.” 

We believe that ORD and OARM have taken

adequate action to reduce ESH risks at ERL Gulf Breeze

based on the 1997 SHEMD audit, SHEMD documentation,

and interviews with Agency officials. No further action is

required.

Ensure that ORD

Coordinates with OARM so

that ORD’s ESH Program

Complements, Rather than

Duplicates, the Agency’s

Program.

ORD identified its ESH program as a material

weakness in Integrity Act reports since 1992. ORD took

action to address its internal control weaknesses by

appointing a full-time industrial hygienist to develop and

manage an ORD-wide program. Plans for the program

included technical assistance and an audit process, modeled

after SHEMD's program, to provide more frequent

evaluations of ORD laboratories. 

According to an official in the ORD’s Office of

Resources Management and Administration, the ESH

program for ORD has been affected by the laboratory

reorganization. ORD reorganized their laboratories after

our 1995 audit so that the divisional laboratories are

grouped by research category under three National Labs (or

“mega-labs”). Each divisional laboratory now has its own

ESH manager, as well as an ESH point of contact at each

mega-lab. ORD is considering a strategy where ORD-wide

and major ESH issues concerning the mega-labs are

coordinated through a Headquarters liaison to OARM.

We believe that ORD’s reorganization and regular

communication between ORD and OARM has sufficiently

addressed our recommendation. No further action is

required. 
7 Report No. 8100185

Instruct OARM to

Identify and Prioritize

Specific Laboratories’

ESH Needs in

Determining ESH

Position Requirements.

During our 1995 review, we questioned whether

adequate consideration was given to appropriate expertise

and skills when filling ESH vacancies at two of the facilities. 

Technical expertise and skills mix are critical components to

having a model, or even an adequate, ESH program. We

recommended that SHEMD assist laboratories in the

identification and selection of needed skill mix and qualified

personnel. SHEMD agreed to offer counsel in hiring ESH

personnel, but did not want oversight responsibility for

personnel decisions of local managers. SHEMD also stated

that it believed that it addressed staff requirement issues

in their ESH audits. We did not agree that these actions

were adequate to completely address ESH personnel

qualification issues. Our report further recommended that

SHEMD make written recommendations to facility directors

on how best to advertise and fill ESH vacancies. Also,

SHEMD concurrence on the experience and expertise of an

ESH position selectee should be obtained prior to filling the

ESH position.

According to the Director of SHEMD, Draft EPA

Order 1440.1 included a section that would require

SHEMD concurrence before filling an ESH position. This

section was not approved during formal Agency

management review of the document because Agency

program offices and regional laboratories did not agree with

the proposal. SHEMD management stated that they have

been informally asked to review candidates for certain ESH

positions, but do not have final concurrence authority. 

Since formal SHEMD involvement in the selection

process will not be implemented, OARM could strengthen

its audit protocol by identifying and prioritizing specific

needs such as training requirements and skill qualifications.

Improve Coordination of

ESH Activities at

Facilities Where Program

Offices Are Co-located.

Research Triangle Park (RTP) has three program

offices with ESH responsibilities: OARM, ORD, and OAR

(Office of Air and Radiation). We found that ORD’s ESH

safety committee did not sufficiently represent the ESH

needs of all three program offices. Additionally, RTP

officials did not appear to coordinate when selecting the

proper skill mix for qualified ESH personnel. We
8 Report No. 8100185

recommended that OARM, in conjunction with applicable

program offices, develop and implement a plan to improve

coordination at facilities where program offices are colocated, such as RTP and Cincinnati, so that there is a

facility-wide ESH program which covers all operations and

addresses facility weaknesses. Our report also

recommended that the SHEMD audit protocol include

review of the coordination plan and its implementation at

applicable locations. 

SHEMD addressed this recommendation by

incorporating issues related to co-located facilities into their

Draft EPA Order 1440.1: Safety, Health & Environmental

Management, which is currently awaiting signature. It

states: 

In Co-located Facilities, where more than

one AA or RA share management of the

SHEMP (Safety, Health, and Environmental

Management Program) program and

implementation strategies, the program will

be integrated into one location-wide or

facility-wide program, by written agreement

between the parties, and there will be clearly

assigned SHEMP delegations of authority,

responsibilities and accountability for

program implementation and evaluation

(e.g., Las Vegas, Cincinnati, RTP, etc.).

We believe that this action addresses the intent of

our recommendation, but urge that OARM follow-up to

ensure that this section regarding co-located facilities

remains in the final version of EPA Order 1440.1. 

Enhancement of Audit

Process Through

Increased Involvement of 

Program and Regional

ESH Personnel in Audits.

Previously, ESH audits were accomplished

exclusively by a SHEMD technical expert serving as team

leader and a contractor team of two to five experts. We

reported that many laboratory managers were critical of

SHEMD’s overdependence on contractors, whose lack of

knowledge of EPA’s background, history, and operations

adversely affected the audits. SHEMD officials explained

that their request for “contractor conversion” to bring more
9 Report No. 8100185

ESH expertise in-house was not approved. However,

laboratory management was willing to provide laboratory

ESH personnel to participate in SHEMD audits of other

Agency facilities if SHEMD would be willing to support

part of the travel expenses incurred. This would allow the

audit participant to acquire training and a greater

understanding of the audit process, while the audit process

and the audited facility would benefit from the experience of

the participant. 

SHEMD began using program and regional ESH

personnel to assist the contract personnel in the ESH audit

process. According to the SHEMD in-house auditor, two

ORD employees assisted in performing audits last year. 

This year, regional employees are scheduled to assist on

several audits. SHEMD is also negotiating with ORD to

fund one or two more people this year. SHEMD

management agreed it is helpful when ESH personnel are

involved in the audit process because EPA employees may

have a better understanding of EPA specific ESH issues. 

Also, audits involving EPA field personnel are perceived by

the facilities more as an “internal review” than a

“Headquarters’ audit.” The Agency has begun enhancing

the audit process by increasing the use of EPA personnel in

the audit process. No further action is required on this

issue. 

Elevation of Reports to

EPA Top Managers when

Reports Identify

Significant Risk.

We were concerned about the lack of visibility of the

ESH audit reports to top management. ESH audit reports

were issued to management one level above the audited

facility. SHEMD did not have a standard protocol for

elevating uncorrected deficiencies, potentially dangerous

situations, or other serious concerns to the next level. 

Therefore, top-management may not have been aware of the

potential impact of at-risk facilities on the Agency as a

whole.

Currently, SHEMD reports for ORD laboratories

are sent to the National Lab Directors and to the divisions. 

Audit reports for regional laboratories are addressed to

either the Deputy Regional Administrator or the Assistant

Regional Administrator. We found several examples where
10 Report No. 8100185

ESH issues were elevated to a higher level of management. 

For example, SHEMD elevated a corrective action report

regarding open findings from Gulf Breeze’s 1993 audit to

both the National Lab Director (ORD) and to the Director

of the Office of Administration (OARM). 

SHEMD also added an executive summary to their

reports to facilitate communication to senior management. 

We agree that inclusion of an executive summary improves

communication; however, the current summary format only

counts numbers of violations and compares them with

previous years’ violations. The summary section would be

more helpful if it presented a risk assessment describing the

laboratory’s progress toward meeting EPA’s environmental

goals to improve environmental performance. (Discussed in

Chapter 3). 

Improvement of the

OARM ESH Audit

Reporting Process. 

Increasing the Timeliness of

Audit Reports and

Associated Responses

In the 1995 audit, we identified concerns with the

timeliness of the audit reports. If results of the audit are not

communicated timely, needed corrective actions may be

delayed. We suggested that one way to address this issue

was to provide a written draft report for laboratory

comment at the SHEMD audit exit conference. We

recommended that OARM increase the timeliness of audit

reports and associated reports, which would include

establishing response time frames for program and Regional

offices.

 

Presently, the audit team debriefs the laboratory

personnel and presents written preliminary summary results

prior to departure. According to a SHEMD official,

providing comments during the exit has reduced the total

audit time-line at the completion of the audit. However, the

SHEMD in-house auditor is not satisfied with the average

overall time it has been taking to complete an audit to final

report. She explained that final reports have been held up

due to additional response time requested by facilities, and

errors (usually typographical) made by the contractor. 
11 Report No. 8100185

We reviewed SHEMD’s updated ESH audit reports

for three of the five facilities included in our 1995 report. 

These audits were performed at Gulf Breeze, RTP, and

Kansas City facilities between 1996 and 1997. Two of the

reports took four or more months after completion of site

work before final issuance. Timeliness in reporting is

important to avoid potential delays in corrective action and

to ensure that upper-management is promptly aware of

EPA’s ESH vulnerabilities. 

SHEMD should focus on further improvement and

consistency in the timeliness of audit reports. Delays could

be avoided by establishing response time frames for

program and Regional offices. 

Incorporation of the Facility

Response to the Draft

Report Into the Final

Report

Previously, laboratory management did not believe

that they received adequate consideration for their

responses for issues addressed in the draft audit report. 

Although SHEMD had made an effort to respond to draft

comments, the feedback process was informal and

ineffective in answering facility concerns. We

recommended that SHEMD address and evaluate Agency

comments to the draft reports in writing in the final report

itself to make it clear to the auditees whether their

responses to the recommendations in the draft were

acceptable and complete. SHEMD management indicated

that they would be willing to consider changing their format

to accommodate this change.

Draft EPA Order 1440.1 states that SHEMD will

incorporate comments of ESH officials from the draft audit

report into the final report. The SHEMD in-house auditor

stated that facility responses are already being considered in

the final report. However, we reviewed several final reports

and were unable to clearly distinguish auditee comments

within the reports. It appears that the audit reports are still

not explicitly demonstrating whether auditees’ responses to

the draft reports were accepted.

SHEMD should ensure that the auditee comment

requirement is included in the final EPA Order 1440.1. 

Additionally, SHEMD should more clearly identify facility

responses to the draft report in the final report. 
12 Report No. 8100185

Improvement of Corrective

Action Tracking 

SHEMD’s initial automated system maintained

corrective action tracking and other audit information. 

However, neither management nor audited facilities could

access the system to review information. Audited facilities,

therefore, could not provide automated updates for

corrective action tracking. The facility had to provide

corrective action status reports to SHEMD in order for the

audit contractor to update the system. SHEMD personnel

stated they were planning to institute a monthly process to

provide reports to field facilities, as both a means to

encourage updates and ensure that Headquarters received

updates. Eventually, SHEMD wanted to have the tracking

system available for review through the Agency's local area

network. We recommended that SHEMD increase the

visibility of and improve access to the corrective action

tracking system.

Improvements to the LAN system now allow some

facilities to review the status of their findings on the

SHEMD database. Quarterly hardcopy reports on open

findings are provided to facilities. Information to update

findings can be sent back to SHEMD through e-mail, by

disk, or in hardcopy. Findings are reviewed by SHEMD

officials and updated in SHEMD’s data base on a monthly

basis. According to SHEMD officials, they would

eventually like to allow facilities to edit and update their

own changes online, but only after SHEMD has

implemented additional controls to the system. According

to a SHEMD official, the timeliness of facility responses has

improved since they started sending quarterly reminder

reports on the status of findings to the facilities. 

SHEMD has improved their corrective action

tracking system to ensure that interim actions are tracked

during long term corrective actions and are working toward

providing additional accessibility for the system to field

facilities and top management. SHEMD officials should

ensure that appropriate access to the system is established.

Conclusion The Agency has improved its ESH management

system and has complied with the majority of our prior

recommendations. However, EPA needs to address the

adequacy of ESH personnel staffing, and finalize ongoing
13 Report No. 8100185

audit process and reporting improvements. Because CEMP

principles closely related to our previous recommendation,

the Agency also needs to consider the model program,

which is discussed in Chapter 3 of this report.

Recommendations We recommend that Acting Assistant Administrator

for Administration and Resources Management: 

2-1 Assist facilities in identifying and prioritizing

laboratories’ ESH needs by strengthening audit

protocol to address training and qualifications to

best complement laboratories' ESH programs. 

2-2 Ensure that the requirement for coordinated ESH

programs at co-located facilities is included in the

final version of EPA Order 1440.1. 

2-3 Further improve the audit process by:

a. Enhancing the executive summary to more

clearly identify risk to assist the Agency in

assessing and improving its ESH

performance goals. 

b. Clearly identifying facility comments/

responses to the draft in the final report.

c. Promoting more timely audit responses and

reporting, which would include 

establishing response time frames for

program and Regional offices. 

d. Increasing access to corrective action

tracking data base with appropriate 

controls.
14 Report No. 8100185

Agency Response Recommendation 2-1

SHEMD agreed to modify its auditing protocol to

strengthen its assessment of training requirements and skill

qualifications for safety, health and environmental managers. 

SHEMD believes that this addition will assist managers with

the preparation and implementation of their individual

development plans. The expected date for completing this

action is October 31, 1998. 

Recommendation 2-2

The Agency addressed coordination of ESH programs at

co-located facilities in the final version of EPA Order

1440.1, signed May 11, 1998. 

Recommendation 2-3

a. SHEMD agreed to add a generic risk assessment

discussion to the executive summary of its ESH

audit reports beginning in August 1998. 

b. In April 1998, SHEMD began to include a tabular

summary of audit findings, auditee comments, and

SHEMD comments with the distribution of the final

audit report. SHEMD also plans to amend its audit

program document to reflect this standard

procedure. 

c. SHEMD stated that it does specify response time

frames for program and Regional office reviews of

draft and final audit reports. In addition, SHEMD

will attempt to improve the timeliness of responses

by assuring that draft reports are sent to senior

managers and that appropriate follow-up actions are

taken. A SHEMD official will also track the status

of corrective actions for audits and an automated 

tickler system will be implemented to assist in

reminding managers of audit response dates by

August 1998. 

d. SHEMD will make its corrective action tracking

system accessible to SHEMP managers when
15 Report No. 8100185

internal control issues are resolved (expected within

the next fiscal year). In the interim, SHEMD will 1)

download the information from the tracking system

into a word processing file, 2) send it through e-mail

to the appropriate SHEMP managers and senior

management officials for an update on the status of

open findings, and 3) request that they forward the

updated file, electronically, to SHEMD to be

uploaded into the corrective action tracking

database. This approach eliminates the need to train

individuals on the occasional use of the database and

stimulate communication between field mangers and

SHEMD officials

OIG Evaluation of Agency

Response

The proposed corrective actions will address the

recommendations and no further action is required.
16 Report No. 8100185

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17 Report No. 8100185

CHAPTER 3

EPA’S IMPLEMENTATION OF CEMP

Although SHEMD has made improvements to

EPA’s ESH management program, it can take additional

steps to be a leader in environmental management. 

Executive Order 12856, Federal Compliance with Right-toKnow Laws and Pollution Prevention Requirements, states

that, “. . . the Federal Government should become a leader

in the field of pollution prevention through management of

its facilities, its acquisition practices, and in supporting the

development of innovative pollution prevention programs

and technologies.” The order directs federal agencies to

agree to sign onto a code of environmental principles

emphasizing pollution prevention, sustainable development,

and beyond compliance environmental management

programs. 

The Code of Environmental Management Principles

(CEMP) is a collection of five principles that provide a basis

for federal agencies to move toward responsible

environmental management and reach the highest levels of

environmental performance. It focuses federal agencies on

the necessity to develop state-of-the-art environmental

management that ensures a best-in-class environmental

program. 

The goal of CEMP is to move Agencies beyond

compliance and the traditional short-term focus on

regulatory requirements to a broader, more inclusive view

of the interrelated nature of their environmental activities. 

Implementing guidance for CEMP notes that short-term

success is no indicator of the long-term stability of the

environmental management system, and may even lead to

complacency. Agencies that fully integrate their system will

be in a better position to identify weak points and predict

future risks, managing their resources for prevention, not

just response. Ultimately, agencies that invest in the
18 Report No. 8100185

implementation of CEMP principles are likely to realize a

high return on that investment through an improved risk

profile at their facilities, resulting in a lowering of costs

associated with regulatory compliance, safety and health,

incident response, and cleanup of contaminated sites. 

The fives principles of CEMP are as follows:

• Management commitment demonstrated through

written policies to support pollution prevention and

compliance.

• Pro-active compliance assurance and pollution

prevention programs to aggressively identify and

address deficiencies and improve environmental

performance. 

• Enabling systems to allow personnel to perform

functions in an environmentally responsible manner.

• Performance and accountability measures to ensure

that expectations for environmentally responsible job

accomplishments are clear.

• Measurement and improvement procedures to assess

progress and use results to reach the highest levels

of environmental performance. 

The CEMP principles relate closely to the

recommendation in our 1995 report that EPA establish a

model environmental program which also addresses safety

and health issues. Laboratory managers and ESH personnel

generally supported the concept that the Agency should

have more than just an adequate ESH program. During

recent fieldwork, officials in OARM agreed that EPA

should work toward developing a model environmental

management program in line with CEMP. Given the fact

that EPA created the environmental regulations and

enforces compliance at federal and private laboratories, it is

important that EPA aspire to fully implement CEMP as a

leader in environmental management, not only in the federal

sector, but in the nation. We evaluated EPA’s

implementation of CEMP, and found three of the five

principles to be particularly relevant to the OIG model

program recommendation. 
19 Report No. 8100185

One of these principles advocates management

commitment toward improved environmental performance

by establishing a written top-management policy which

emphasizes pollution prevention and the need to ensure

compliance with environmental requirements. Private

companies have demonstrated their dedication to improving

safety and environmental performance through written

statements. For instance, DuPont’s CEO prepared a written

report publicizing the company’s safety, health and

environmental accomplishments, including energy savings

and decreases in toxic and ozone depleting emissions. 

General Motors adopted a policy statement, GM

Environmental Principles, affirming the company’s

commitment to a safe and healthy environment. EPA’s top

management could issue a similar policy statement

committing EPA to improved environmental performance. 

We also found that environmental management for EPA

facilities is not prominently addressed as a priority in EPA’s

1997 strategic plan. In our opinion, such a policy document

from EPA, as well as clear strategic plan support, could

enhance the Agency’s environmental commitment and

performance.

Another CEMP principle involves performance and

accountability, recommending agencies develop measures to

address employees’ environmental performance and ensure

full accountability of environmental functions. Commitment

to responsible environmental management should be

integrated into Agency policy by including requirements in

employee performance standards and awards criteria. In

our previous audit, we found that employees’

responsibilities for the ESH programs did not appear to be

addressed in performance ratings. We also examined an

Environmental Management Review (EMR) of an EPA

laboratory completed this past year by EPA regional

pollution prevention staff. The EMR found that the

laboratory staffs’ environmental roles and responsibilities

were not clearly defined and that the environmental impacts

of laboratory operations were not fully understood by all

laboratory personnel. It is important that employee

environmental performance is addressed in their

performance standards and that Agency personnel
20 Report No. 8100185

understand and are held accountable for their environmental

responsibilities. 

Measurement and improvement of the Agency’s

environmental performance and goals is the third relevant

principle. SHEMD stated that risk assessments are

completed by comparing individual laboratory ESH audit

results from year to year. However, we do not believe that

this information clearly identifies environmental risk

Agency-wide. An Agency-wide assessment would allow

EPA to classify its risk in different areas (e.g., training,

building and fire safety, management support). Then, EPA

can determine the most significant areas of weakness and

respond accordingly toward environmental, safety, and

health performance organization-wide. This assessment

would also allow the Agency to evaluate its progress

toward meeting overall environmental goals. 

Conclusion The Agency has improved its environmental, safety,

and health program, and is now ready to meet the next

challenge. CEMP encourages federal agencies to emphasize

responsible environmental management. In its role as a

leader both nationally and internationally in environmental

programs, the Agency should also be a leader in setting a

standard for excellence in implementing responsible

environmental management at its laboratory and facility

operations.

Recommendations We recommend that Acting Assistant Administrator

for Administration and Resources Management: 

3-1 Move EPA toward meeting the highest levels of

environmental performance in line with CEMP. 

Steps include:

a. Demonstrate management commitment

through a written top-management policy. 

b. Develop measures to address employee

environmental performance and ensure full

accountability of environmental functions. 
21 Report No. 8100185

c. Strengthen the risk assessment of the Agency

as a whole so that EPA can determine areas

of weakness and respond toward improving

environmental performance. 

Agency Response Recommendation 3-1(a)

SHEMD is currently reviewing corporate policies and

management commitment statements by Corporate

Executive Officers and other Federal Agency Heads. 

SHEMD plans to have a similar statement available for

signature by the Agency’s senior management by November

1, 1998.

Recommendation 3-1(b)

SHEMD stated that the accountability requirement for

environmental performance by senior management is

contained in the EPA Order 1440.1. SHEMD reviews the

performance standards of managers as part of its

management systems review during audits. Incorporating

environmental systems and establishing a corporate culture

of laboratory workers will be presented at SHEMD’s

national workshop for EPA safety, health and environmental

managers in July 1998. SHEMD will upgrade its auditing

protocol by December 1998 and will assist auditors in

evaluating the extent to which environmental management

principles have been instilled in the work ethic of managers

and employees. 

Recommendation 3-1(c)

SHEMD agreed to add an interpretation section to their

annual summary addressing Agency risk attributable to

observations made during audits for fiscal year 1998. This

report is typically completed by November 15th of each year.

OIG Evaluation of Agency

Response

We agree with the Agency’s actions for this

recommendation. No further action is necessary.
22 Report No. 8100185
23 Report No. 8100185

APPENDIX I

RESULTS OF 1995 AUDIT

ESH PROGRAM

In our 1995 audit, we found that, although EPA’s ESH Program for laboratories was

improving, it was inadequate overall. The ESH programs at five laboratories were evaluated and

the performance of critical ESH program elements rated as model, adequate, or inadequate. 

Elements included industrial hygiene support, building and fire safety support, environmental

management support, facility ESH self-inspection, building and facilities support, ESH committee,

management support and involvement, ESH professional and best management practices,

contractor monitoring and interface, and training. 

All facilities were rated inadequate in at least two of the ten elements. One laboratory

(Gulf Breeze) was rated inadequate in nine of ten elements. We believe that an inadequate rating

in even one element leaves the facility vulnerable. Given EPA’s position in the regulated

community, EPA should become the leader in developing a model environmental program. This

model program would provide a management tool to assist in assessing and improving the ESH

program at Agency laboratories. 

To improve EPA’s program, we recommended that the Deputy Administrator: 

• Declare EPA’s Environmental, Safety and Health (ESH) programs, at a minimum, an

Agency-level weakness during the 1995 Integrity Act process, unless immediate actions

result in major program improvements.

• Require OARM, in conjunction with the program offices, to develop a model

environmental program which also adequately addresses occupational safety and health

requirements to provide a management overview as a supplement to present ESH audit

protocol. Establish clear expectations and ensure that the program is implemented at all

Agency laboratories.

a. As needed, OARM should make improvements to the program element matrix

contained in this report and use it as the basis for an ESH report card to be

completed by SHEMD officials at the time of their facility audit or annually if ESH

conditions warrant.
24 Report No. 8100185

b. OARM should work with program and Regional offices to develop corrective

action plans to address report card weaknesses and improve the ESH program.

c. Regional Administrators should be instructed to reassign the ESH allocated

resources (.7 FTE per Region) to the regional laboratories unless compelling

written justification is provided by the Regional Administrator, concurred in by

SHEMD, and approved by the Assistant Administrator, OARM. 

• Instruct ORD and OARM to take immediate action to reduce ESH risks at Environmental

Research Laboratory (ERL) Gulf Breeze and document completed actions. 

• Ensure that ORD coordinates with OARM so that ORD’s ESH program complements,

rather than duplicates, the Agency’s program.

• Instruct OARM to identify and prioritize specific laboratories’ ESH needs in determining

ESH position requirements to best complement laboratories’ ESH programs.

a. Require SHEMD to make a written recommendation to the facility director on

how best to advertise and fill full-time ESH vacancies. The recommendation

should indicate what skill mix will most improve the report card ratings.

b. SHEMD concurrence on the experience and expertise of an ESH position selectee

must be obtained prior to filling the ESH position.

• Instruct OARM, in conjunction with applicable program offices, to develop and implement

a plan to improve coordination at facilities where program offices are co-located, such as

RTP and Cincinnati, so that there is a facility-wide ESH program which covers all

operations and addresses facility weaknesses. Incorporate review of the plan and its

implementation into SHEMD audit protocol.

ESH AUDIT PROCESS

At the time our 1995 OIG review was completed, we found that OARM needed to

improve the ESH audit process and its visibility to management. Several factors contributed to

criticism of the ESH audit process by EPA laboratory managers. Among the concerns addressed

were: use of contractors to perform the audits; treating professional practice findings and

recommendations in the same manner as regulatory findings and recommendations; a less than

timely release of draft and final reports; and inadequate consideration of laboratory responses to

issues addressed in the draft reports.
25 Report No. 8100185

We recommended that the Deputy Administrator:

• Instruct OARM to enhance the ESH audit process by involving program and Regional

ESH personnel in audits.

• Establish a process in OARM to elevate reports to EPA top managers when reports

identify significant risk or continuing problems found during ESH audits.

• Improve the OARM ESH audit reporting process by:

a. Increasing the timeliness of audit reports and associated responses, which would

include establishing response time frames for program and Regional offices;

b. Incorporating the facility’s response to the draft report into the final report, which

would include an evaluation of facility comments and a clear identification of

where SHEMD and the facility are not in agreement;

c. Improving corrective action tracking (for example, ensuring that interim actions

are tracked during long term corrective actions, and providing additional

accessibility of the tracking system to field facilities and top management).
26 Report No. 8100185

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27 Report No. 8100185

APPENDIX II

AGENCY RESPONSE

July 10, 1998

MEMORANDUM

SUBJECT: Follow-up Audit of Environmental, Safety, and Health Issues at EPA 

Laboratories, Draft Audit Report No: E1DMD8-11-0002

FROM: Alvin M. Pesachowitz /s / by John Sandy

Acting Assistant Administrator

 for Administration and Resources Management (3101)

TO: Michael Simmons

Deputy Assistant Inspector General for Internal Audits (2421)

We appreciate your follow-up review of “Environmental Safety and Health Issues at EPA

Laboratories.” Independent program reviews help to assure that we are managing our activities

properly and that we are addressing the needs of our customers. 

I am pleased that you found a much improved environmental, safety, and health program

during this follow-up review. We generally concur with the new recommendations in your draft

report and believe that they will help to further enhance our nationwide program. As input to

your final report, we are providing comments, accomplishments, and our proposed corrective

actions to your recommendations. 

Should you or your staff have any questions regarding this response, please feel free to

contact Julius Jimeno at 260-1640.

Attachment
28 Report No. 8100185

cc: Deputy Administrator (1102)

 Assistant Administrator for Research and Development (8101R)

 Assistant Administrator for Enforcement and Compliance Assurance (2201A)

 Director, Office of Administration, OARM (3201)

 Director, Office of Resources Management and Administration, ORD (8120R)

 Director, Safety, Health, and Environmental Management Division (3207)

 Director, Federal Facilities Enforcement Office, OECA (2261A)

 OARM Audit Liaison (3102)
29 Report No. 8100185

Environmental, Safety, and Health (ESH) Issues at EPA Laboratories

Draft Audit Report No. E1DMD8-11-0002

Comments, Accomplishments, and Proposed Corrective Actions

Chapter 2

2-1 Assist facilities in identifying and prioritizing laboratories’ ESH needs by 

strengthening audit protocol to address training and qualifications to best 

complement laboratories’ ESH programs.

The Safety, Health, and Environmental Management Division (SHEMD) agrees with this

recommendation and will modify its audit protocol to strengthen our assessment of the training

requirements and qualifications of the Agency’s safety, health, and environmental management

program managers (SHEMPMGRs). This will assist our SHEMPMGRs and their supervisors

with the preparation and implementation of their career and individual development plans. We

will discuss this matter at our technical training conference this month, and expect to enhance our

audit protocol by October 31, 1998. We will also be discussing these matters with the

certification boards for the technical professions associated with our program.

2-2 Ensure that the requirement for coordinated ESH programs at co-located 

facilities is included in the final version of EPA Order 1440.1. 

EPA Order 1440.1 was signed on May 11, 1998, and provides direction for programmatic

issues at the Agency’s co-located facilities. A copy of the signed order was provided to Carolyn

Blair of the IG Audit staff. 

2-3 Further improve the audit process by:

 a. Enhancing the executive summary to more clearly identify risk to assist the 

Agency in assessing and improving its ESH performance goals.

SHEMD will include a generic discussion of risk assessment in the executive summary

section of audit reports, beginning in August 1998.

 b. Articulating facility comments/responses to the draft in the final report.

Although there is no specific requirement that auditee comments be addressed in writing in

the final report in EPA Order 1440.1, this has always been a standard practice. In April 1998,

SHEMD improved the process by including a tabular summary of audit findings, auditee

comments, and SHEMD’s comments with its final audit report. We trust that this action meets
30 Report No. 8100185

the intent of your recommendation. We will amend our audit program documentation to clarify

this standard practice. A copy of the summary of comments and responses for the Las Vegas 

audit was also forwarded to Carolyn Blair. 

 c. Promoting more timely audit responses and reporting.

Currently, SHEMD does specify response times for Program and Regional Office reviews

of its draft and final audit reports. Typically, responses are requested within 21-28 days. We will

be sending draft reports to senior managers and follow-up with them to improve the timeliness of

responses. We have assigned a SHEMD employee to specifically track the status of responses to

SHEMD audit reports and periodic submittal of corrective action plans, using an automated

tickler system. These system improvements will be implemented by August 31, 1998.

 d. Increasing access to the corrective action tracking data base. 

As soon as all internal control issues can be resolved (which is expected to be completed

within the next fiscal year), SHEMD will make its corrective action tracking system accessible to

SHEMPMGRs. In the interim, our strategy is to: (1) download the information from the tracking

system into a word processing file; (2) send it through e-mail to the appropriate SHEMPMGRs

and senior management officials for an update on the status of open findings; and (3) request that

they forward the updated file, electronically, to SHEMD so that it can be uploaded into the

corrective action tracking database. This technology-based interim approach would eliminate

training and retraining individuals on the occasional use of the database (quarterly) and stimulate

our field managers to provide regular responses to, and communications with, SHEMD’s tracking

system coordinator. 

Chapter 3

3-1 Move EPA toward meeting the highest levels of environmental performance 

in line with the Code of Environmental Management Principles (CEMP) by:

 a. Demonstrate management commitment through a written top-management 

 policy.

SHEMD has been reviewing corporate policies and management commitment statements

signed by Corporate Executive Officers and other federal Agency heads. We expect to have a

similar statement ready for the Administrator by November 1, 1998.
31 Report No. 8100185

 b. Develop measures to address employee environmental performance and 

 ensure full accountability of environmental functions.

The accountability requirement for environmental performance by senior management is

contained in EPA Order 1440.1, Safety, Health, and Environmental Management Program; and

SHEMD does review performance standards of managers as part of its management systems

review during its audits. Incorporating environmental management systems and establishing a

corporate culture of laboratory workers will be presented at its national workshop for EPA safety,

health, and environmental managers from July 20-24, 1998. SHEMD will upgrade its auditing

protocol in this area by December 1, 1998, and it will help its auditors evaluate the extent to

which environmental management principles have been instilled in the work ethic of managers and

employees.

 c. Strengthen the risk assessment of the Agency as a whole so that EPA can 

 determine areas of weakness and respond toward improving environmental 

 performance.

SHEMD prepares an annual report usually by November 15 which summarizes the findings

and results of its auditing program. The report is a “numerical” summary of the information

collected from audits performed during that fiscal year. Beginning with this fiscal year 1998

report, SHEMD will add an interpretation section to its annual summary addressing Agency risk

attributable to the observations made during the audits. 
32 Report No. 8100185

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33 Report No. 8100185

APPENDIX III

DISTRIBUTION OF REPORT

Inspector General

Deputy Inspector General for Audit

Divisional Inspectors General

Deputy Administrator 

Assistant Administrator for Research and Development 

Assistant Administrator for Enforcement and Compliance Assurance 

Director, Office of Administration, OARM 

Director, Office of Resources Management and Administration, ORD 

Director, Safety, Health, and Environmental Management Division 

Director, Federal Facilities Enforcement Office, OECA 

OARM Audit Liaison