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Chapter 11
11.13. Mass Highway Self-Audit Procedure

Example 25 : Mass Highway Self-Audit Procedure

This section presents an overview of the procedures and roles and responsibilities for conduct of Mass Highway Self-Audits. The actual Mass Highway Self-Audit Protocol Handbook is available for a detailed discussion of the procedures and roles and responsibilities. The procedures discussed below generally involve five Mass Highway staff members; the Audit Coordinator, the Lead Auditor, District Maintenance Engineer, the Facility Forman and the District HazMat Coordinator. There are three Phases to a Mass Highway Self-Audit; the Pre-audit Preparation, the Audit Site Visit and the Post Audit Phase. The process is described below.

Pre-audit Preparation. The Audit Coordinator prepares a schedule for facility audits. Once the schedule has been prepared, the Audit Coordinator will designate a DHC as the District Lead Auditor. The Lead Auditor will be a DHC from a District other than the one being audited. The Lead Auditors are provided with facility and District contact information needed to complete the self-audit notifications, site visit, and follow up reporting. The Lead Auditor will notify the DHC and DME in the District of the scheduled audit at least two weeks in advance of the audit. The DHC and DME will ensure pre audit questionnaires are completed, Facility foremen are contacted, and that facility records are made available at the time of the audit.

Audit Site Visit. The Lead Auditor will conduct a pre-audit briefing with facility personnel to 1 ) inform facility personnel of the purpose of the audit; 2 ) inform facility personnel of their audit responsibilities and required participation in the audit; and 3 ) answer any preliminary questions the facility personnel may have regarding the audit. After the briefing, the Lead Auditor conducts a facility walkthrough, recording any environmental compliance findings in field notes and facility plans. The Lead Auditor also performs a record review of applicable compliance documents, such as manifests and environmental permits. During the walkthrough and records review, the Lead Auditor completes the Audit Protocol Checklist. Findings that may be immediately corrected should be completed during the walkthrough and documented by the auditor. The Lead Auditor then conducts exit briefings and submits the draft findings list to the Facility Foreman at the completion of each audit. The list is provided so facility personnel may initiate corrective actions in advance of receiving a Corrective Action Report ( CAR ) .

Post Audit Phase. Following the audit site visit, the Lead Auditor prepares a CAR, which summarizes the audit findings. An electronic version is forwarded to the Audit Coordinator and the DME. Upon receipt of the CAR, the DME coordinates with the facility foreman to ensure facility personnel conduct the necessary corrective actions. DHCs are responsible for correcting or managing corrective actions that fall outside operational responsibility of the Facility Foreman or DME.

The Facility Foreman ensures that the corrective actions have been completed and documents corrective actions in the space provided on the CAR. The completed CAR is forwarded to the Lead Auditor for review and confirms that the completed actions adequately address the findings on the CAR. The completed CAR is forwarded to the Audit Coordinator along with a memo that summarizes the completed self-audit.

For each unresolved regulatory finding, the Lead Auditor completes a Clean State Matter Report ( CSMR ) . If a completed CAR has not been received within 14 days of the audit a CSMR is completed for all regulatory findings identified on the original CAR. Within two days of receiving the completed CAR, the Lead Auditor forwards all audit field notes, checklists, completed CAR, and CSMRs to the Audit Coordinator for archiving in the Environmental Section's Self-Audit Program files. The Audit Coordinator will enter all unresolved regulatory findings documented on the CSMRs into the EOEA's Clean State Database.

The Audit Coordinator provides the audit findings to the DHC. The DHC will complete and transmit to the Audit Coordinator and DME a Corrective Action Plan ( CAP ) for each unresolved regulatory finding on the completed CAR. The DHC will provide quarterly CAP progress reports to the Audit Coordinator until the CAP has been completely resolved. The Audit Coordinator will enter the updates into the Clean State database. Once a CAP has been completely resolved, the Audit Coordinator will complete and submit a request for de-listing of a regulatory finding from the EOEA's Clean State Coordinator and the Clean State database.

A summary of the timelines described in the preceding sections for conducting Self-Audits and audit follow-up activities is provided below.


Responsible Person


Assign Audit Team and Lead Auditor

Audit Coordinator

According to Annual Schedule

Notify DHC, DME, and Facility foreman of impending Self-Audit

Lead Auditor

At least two weeks before audit site visit date

Complete and submit CAR to DHC, DME, and Foreman

Lead Auditor

Within two days after audit site visit.

Complete and submit CAR and CCAR to Lead Auditor


Within 14 days of the date the audit was conducted

Complete audit summary memo and CSMRs and submit to Audit Coordinator

Lead Auditor

Within 1 week after receipt of CCAR or within 2 days of CCAR due date

Enter audit results into Clean State database and submit final CAR to DHC

Audit Coordinator

Within 2 weeks after receipt of CCAR from Lead Auditor

Complete Corrective Action Plan


Within 21 days after receipt of final CCAR from Audit Coordinator

Complete CAP Progress Reports


Quarterly - ongoing until Final CAP Completion Report issued

Update of Clean State database

Audit Coordinator

Quarterly - ongoing until Final CAP Completion Report issued

Mass Highway has a thorough system for performing environmental audits of maintenance facilities. This system and accompanying tools will be discussed in greater detail in the Facilities section. Checklist items cover hazardous waste, solid waste, water quality and natural resources, as follows, and include space to note comments and needed corrective actions.


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Table of Contents
Chapter 11
11.1 Florida DOT Environmental Policy 11-1
11.2 Kentucky Transportation Cabinet Environmental Policy 11-1
11.3 Maine Dot Environmental Policy 11-2
11.4 North Carolina DOT Environmental Stewardship Policy 11-3
11.5 PennDOT’s Green Plan Policy Statement 11-3
11.6 Washington State Dot Environmental Policy 11-4
11.7 New South Wales Roads and Traffic Authority Environmental Policy 11-4
11.8 Texas Environmental Commitment Checklist 11-5
11.9 Maine DOT Environmental and Safety Auditing Policy and Procedure 11-11
11.10 Maine DOT Corrective Action Request Form 11-14
11.11 Mass Highway Compliance Tracking Methods 11-15
11.12 Mass Highway Compliance Tracking Roles and Responsibilities 11-16
11.13 Mass Highway Self-Audit Procedure 11-17
11.14 Mass Highway Facility Self-Audit Checklist 11-18
11.15 Mass Highway Environmental Roles & Responsibilities 11-20
11.16 Mass Highway Environmental Section EMS Roles and Responsibilities 11-20
11.17 Mass Highway Operations Division EMS Roles and Responsibilities 11-22
11.18 Mass Highway District EMS Roles and Responsibilities 11-23
11.19 Mass Highway Training Expectations By Role 11-24
11.20 Mass Highway Environmental Training Program Roles and Responsibilities 11-25
11.21 PennDOT District 10 SEMP Responsibility Table 11-26
11.22 PennDOT District 10 SEMP Training Table 11-28
11.23 NYSDOT Construction/Environmental Training Schedule 11-29
11.24 Environmental Checklist for MoDOT Facilities 11-30
11.25 PennDOT Stockpile Quality Assurance Responsibilities 11-33
11.26 PennDOT 15-Minute Stockpile Walkaround 11-34
11.27 PennDOT Stockpile Snapshot 11-34
11.28 PennDOT Maintenance Stockpile Activity Protocol 11-35
11.29 PennDOT Post-Storm Salt Management Tracking Responsibilities 11-41
11.30 Risk, Compliance Issues, and Management Examples for Highway-Generated Waste - Oregon DOT 11-42
11.31 NYSDOT-DEC Deer Carcass Composting – Practice Guidelines 11-43
11.32 NYSDOT’s Draft Metric for Assessing Performance of Integrated Vegetation Management on ROW 11-47
11.33 NCDOT Roadside Vegetation Management Guidelines in Marked Areas 11-50
11.34 Invasive Species Coordination and Control DOT Resources
Lists: Examples | Tables | Figures
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