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Internal Audit Report # 12-01 Auditor Audit Date Purpose: Peterborough Utilities Services Inc
Internal Audit Report # 12-01 Auditor Audit Date Purpose: Peterborough Utilities Services Inc
12-01
AUDITOR
Patricia Skopelianos
AUDIT DATE
PURPOSE
The purpose of the internal audit is to obtain objective evidence of the Municipality of
Trent Hills compliance to the Drinking Water Quality Management Standard (DWQMS)
as documented in the Operational Plan.
SCOPE
Elements 1-21
REFERENCE DOCUMENTS
Drinking Water Quality Management Standard - June 2007
Trent Hill Operational Plan Rev 5 July 2012
Standard Operating Procedures (SOP) as described
Previous Audits Reviewed TH11-01
STAFF AUDITED
Mike Rutter, Chief Administrative Officer (CAO)
Scott White, General Manager of Infrastructure Renewal & Public Works Admin.
Scott Campbell, QMS Representative
Todd Kerr, Operator
Paul Kelly, Operator
SUMMARY
The internal audit conducted on October December 12 & 19th, 2012 was the annual
audit for the DWQMS. The Operational Plan and associated SOP were well
documented and in accordance with the Standard. The understanding of the
procedures was extensive through the operational staff. There were a few areas of
non-compliance, which were mainly dealing with additional follow up required to
complete the entire process. With the completion of the corrective actions issued as a
result of the audit, the overall compliance is suitable and the implementation has been
effective.
Element 1
Reference Documents:
Element 2
Element 3
Element 4
Element 5
Compliant
Reference Documents:
Non-conformance
CAR 2012-01
Issued to:
Compliant
QMS Representative
Reference Documents:
Compliant
Reference Documents:
Compliant
Reference Documents:
TH12-01
QMS Representative
There is no evidence that the water regulations have been reviewed since 2010.
Paragraph 4.0 describes the process for change to documents but this process is not
performed as described. The approval is provided after the changes are made but
before they are posted rather than before they are made as described. The SOP
should be updated to describe actual practice.
Comment
paragraph 3.5.6 is seldom used and should be removed as it is not
required. The original signed version of the Operational Plan is kept at the
Campbellford WTP but it is not described where, at the time of the audit we could not
find it. The SOP should describe in greater detail where this document should be kept if
required.
Element 6
Reference Documents:
Element 7
Reference Documents:
Compliant
Compliant
TH12-01
3
Element 8
Reference Documents:
Non-conformance
CAR 2012-02
Issued to:
The critical control point of back flow prevention has been previously identified as a nonconformance and it was described that the program was to be implemented. There is
still not a backflow prevention program for Trent Hills as required under element 8 of the
DWQMS.
Comment
Paragraph 2.6 should be updated to accommodate a greater range of
SCADA limits.
Element 9
Reference Documents:
Element 10
Element 11
Reference Documents:
Element 12
Competencies
Reference Documents
Comment
Compliant
Communication
Reference Documents:
Compliant
Compliant
TH12-01
4
Element 13
Reference Documents:
Reference Documents:
Element 15
Compliant
Reference Documents:
Reference Documents:
TH12-01
5
Opportunity for Improvement
There is a process that Operators follow for verifying the accuracy of online
monitors daily. If the Operators grab sample and the online read out are
different the operator will re-sample 3 times before adjusting or calibrating the
equipment. This process is not described but is a best practice and should be
included in this SOP.
Opportunity for Improvement
When the Operator are performing the work order on the calibration standards or
pillow packages, they should be documenting the lot numbers and expiry dates
of the standards to be able to verify if they are or were expired.
Opportunity for Improvement
Schedule log should also include the serial numbers of the portable units.
Comment
Element 17
Reference Documents:
Element 18
Element 19
Emergency Management
Reference Documents:
Compliant
Internal Audit
Reference Documents:
Non-conformance
CAR 2012-03
Issued to:
Compliant
QMS Representative
The internal audit was scheduled beyond the required 12 months of SOP-07 and the
Standard.
TH12-01
6
Element 20
Management Review
Reference Documents:
Non-conformance
CAR 2012-04
Issued to:
QMS Representative
There is no evidence that actions items discussed at the recent Management Review
were described in the meeting minutes including the deficiencies, responsibilities,
resources and timelines for completions as per 5.0 of SOP-06.
Element 21
Continual Improvement
Reference Documents:
CLOSING SUMMARY
Corrective Action Issued
4
Opportunities for Improvements 6
Comments
4
Compliant