WEIGHTS AND MEASURES Protocol for Auditing of Local Authority Notified Bodies (LANB) for EC Verification Guidance for Local Authorities December 2010 Version 4 Page 1 of 15 Introduction 1.1 This protocol lays down a framework through which Local Authorities wishing to operate as Notified Bodies (Approved Bodies) for the task of EC verification under the non automatic weighing machines and measuring instruments directives can be independently audited. It also allows for NMO on behalf of the Secretary of State to be satisfied that the core criteria of Directive 2009/23/EC and 2004/22/EC continue to be adequately fulfilled. 1.2 Notified Bodies may, within the core criteria, be organised in a number of different ways and it will be for the NMO to establish whether the Notified Body continues to operate within the scope of its designation. The Notified Body also has a responsibility to inform NMO of any changes which might affect its designation. Where personnel from other authorities operate under the scope with the agreement of the Notified Body they must be accountable to the Notified Body whenever the task of EC verification or activity associated with the task is being carried out. This must include, inter alia, documentation/document control, training records, the use of appropriate local and working standards and appropriate insurance cover. The Notified Body may take one of the following forms whose structure and accountability must be identified within the Quality System (QS) documentation which, although may evolve over time, must remain within the scope of the designation: Single Local Authority (personnel solely from within own authority) Group of Local Authorities (Local Authorities from within the group operating under joint arrangements) e.g. Glamorgan Group Separate Legal Entity’s e.g. SWERCOTS or EETSA 1.3 The auditing process will be based around 4 yearly re-assessment audits using the audit checklist (see Annex 1), of the entire quality system that each Notified Body operates. The 4 yearly audits will be interspersed with yearly surveillance visits which will focus on 3 random aspects from the audit checklist ensuring that all aspects are covered over the 3 year period. (see Annex 1). The system will continue to be run on a peer auditing system. Four Yearly Re-assessments 1.4 These will consist of a complete audit of the entire quality system and the results will be formally submitted to NMO by the auditor whereby an administration charge will be made at a cost of £225 to the audited authority. The re-assessment audits are to be a comprehensive check of the Notified Body with the auditor making a decision if the audited Authority is still suitable to maintain notified body status. This audit will based on all seven of the points in the audit check list (Annex 1) Yearly Surveillance Visits 1.5 These will consist of a spot check of three out of the seven points in the audit checklist (Annex 1). With a write up (Annex 2) to be submitted to NMO, no charges will be made for this process. All seven aspects must be covered at least once in any of the three surveillance visits in any four yearly re-assessment cycle. Organisation 2.1 NMO will have an administrative role in each surveillance audit as well as coordinating the overall planning of the audits by acting as overseer of the protocol. Should suitable arrangements not be made in the time frames set out in this protocol NMO reserves the right Page 2 of 15 to conduct audits themselves at direct hourly cost to the Notified Body involved or withdraw designations. If audits are not up to date and if the situation remains un-rectified, NMO will remove the notified body designation. 2.2 This protocol facilitates a mechanism for inter-authority auditing to take place between LANB’s. It is not recommended that reciprocal auditing arrangements take place on more than 2 occasions for the 4 yearly reassessment audits, However, for Regional Groups and Surveillance visits reciprocal arrangements may take place. The LANB must designate an auditor for the 4 yearly assessments and make NMO aware of the selected auditor in advance. This person will be responsible for the audit report and recommendations made to NMO. In the case of Groups of Local Authorities the production of an audit plan to ensure all aspects of the notified body activities are assessed over time will need to be submitted to NMO prior to any audit taking place. 2.3 NMO will require all LANBs to submit the name/s of the suitably qualified personnel who will conduct the 4 yearly re-assessments. NMO will keep a master copy of the list and make it available on the NMO website. LANBs will be required to ensure NMO are kept up to date of any changes in personnel, failure to do so will result in non-conformities being raised. 2.4 Criteria for the auditors who carry out the 4 yearly re-assessments are as follows: Auditors will have attended and passed a recognised lead auditor course, have experience of internal and external assessments, have experience in management of teams for internal or external assessment activities and have a current and proactive interest in metrology. They will not be required to be on the IRCA Register (International Register of Certificated Auditors). For surveillance visits the requirements will be those studying towards auditing qualifications that possess experience of internal auditing and have an interest and relevant knowledge of metrology. 2.5 Where inter-authority auditing is carried out NMO reserves the right to witness such audits at no additional cost to the LANB. This is unlikely to take place for more than 5% of the LANBs audited. NMO would inform the LANB in due time where this is to take place. 2.6 As an alternative to inter-authority auditing a LANB may invite NMO to carry out the audit for a fee. For an organisation not currently designated as a notified body, NMO will conduct the initial audit. 2.7 An audit schedule drawn up by NMO, based primarily on the date of designation and taking into account other related issues e.g. local government re-organisation and actual work load, will set out those authorities to be audited. All designated LANBs who fail to make suitable arrangements within the time schedules set out in this protocol will either be audited by the NMO at direct cost to the LANB or have their designation withdrawn. 2.8 LANBs will refer to the audit schedule on NMO’s website for information on audit dates. 2.9 The LANB should provide the auditor with a copy of their completed application form and/or designation letter issued by NMO (plus any amendments) where the LANB is being audited for the first time. For subsequent audits the LANB should provide details of any amendments to the designation since the previous audit and details of the previous audit report if requested by the auditor. Page 3 of 15 Where no contact has been made, NMO will contact the LANBs one month before the expected date of completion of the audit to remind them of the obligation for the audit to take place. It is for the LANB to inform NMO the name of the auditor and the local authority they are from. 2.10 If the LANB designation is withdrawn then the LANB may make an appeal to the Secretary of State, SoS regarding this withdrawal. The SoS will consider the appeal and provide a formal response to the LANB concerned within 10 working days. The Audit Process 3.1 The audit process will be based on the following: 3.2 Auditors will conduct the audits on a similar basis to an ISO 9001 audit. The audit must include all the conditions referred to in the core criteria of the Directives. These points may be satisfied by the application of the appropriate requirements of the relevant harmonized standards i.e. BS EN ISO/IEC 17020:2004 General criteria for the operation of various types of bodies performing inspection and BS EN ISO/IEC 17025:2005 General requirements for the competence of testing and calibration laboratories. For a checklist of the essential elements to be included within the audit see Annex 1. 3.3 If the LANB being audited is already accredited to ISO 9001, BS EN ISO/IEC 17020:2004 and/or BS EN ISO/IEC 17025:2005 then these aspects of the audit will not need to be duplicated, the audit will merely check to ensure the validity of the accreditation. 3.4 Where the Notified Body being audited covers more than one Local Authority (joint arrangements) then the auditor must consider the most appropriate method for carrying out the audit which ensures the adequacy of the audit both at the strategic and operational levels i.e. head office and at individual Local Authority level. When auditing a Notified Body covering more than one Local Authority the auditor must ensure that each Local Authority audited is operating to the Notified Body’s documented quality system and that such an integrated system exists which meets the requirements of the core criteria and the relevant standard. An action plan must be in place to ensure that all the Local Authorities and all elements of the QMS are audited on a planned basis over successive audits. 3.5 Named person/s will also have to prove/demonstrate competence in verification testing. They will need to be able to satisfy the auditor that they can competently carry out EC verification testing they are authorised to carry out. This may be done by way of a simulated demonstration if necessary. 3.6 Non-conformities (NC) will be identified as: Nonconformity – 1. Non-fulfilment of a requirement (ISO 9000:2005) 2. Breakdown in the quality system which requires a written corrective action and has to be satisfactorily implemented and verified in order for the nonconformity to be closed. Nonconformity, Major – 1. The absence of, or the failure to implement and maintain all aspects of one or more requirements for certification/registration. Page 4 of 15 2. A number of minor nonconformities against one or more requirements, which when combined, can represent a breakdown of the organisation’s systems; or 3. A minor nonconformity that was previously issued and not addressed effectively. Nonconformity, Minor – An observed lapse in the organisation’s quality system potentially impacting on the quality of the product delivered to the customer. Opportunities for Improvement – Documented statements that may identify areas for potential improvement in the organisation’s system, but shall not include specific recommendations nor require action by the organisation. 3.7 Examples of what might constitute a major or minor non-conformity can be found at Annex 3. The “level” of any non-conformity found must be indicated in the audit report in the space provided. Once Completed 4.1 The auditor will be required to produce a report in the form of Annex 2 of the findings, crossreferenced to the NCs found and proposed corrective action. This report must record all areas audited, not just those areas where NCs were found. 4.2 Major nonconformities will usually result in the Notified Body ceasing all Notification activities until the corrective actions have been signed off. The auditor may make an exception to this, or require only a partial suspension, if there are exceptional extenuating circumstances. Any corrective action must be completed within 2 months of the audit having taken place, with proof that the actions have been addressed sent to the auditor. Once completed the audit and evidence of corrective actions have been sent to the auditor, the final report can be sent to NMO. Failure to complete corrective actions within 2 month, may result in designations being withdrawn. 4.3 The auditor is required to advise NMO in writing when the auditing is complete and any outstanding corrective actions have been implemented. This advice together with hard copies of the completed audit report and yearly surveillance visits and supporting audit report(s) should be emailed to notified.bodies@nmo.gov.uk as a word or pdf document. Where the time scale for completing the audit has been exceeded by more than 1 month the auditor should advise NMO of the current position. 4.4 Where the advice given is that the NCs cannot be corrected within the allotted time then NMO will, following consultation with the LANB and where a satisfactory outcome cannot be achieved, advise the LANB that the designation may be terminated. 4.5 In the case of any designation being terminated NMO also contact the European Commission via NANDO input updates. 4.6 For each LANB audited a fee to cover NMO administrative costs including assessment, moderation and notification to the Commission and other associated activities will be charged. It is estimated that this should not exceed £225 for the financial year 2011/12, unless circumstances require a greater level of involvement from NMO. Where NMO is directly involved in the actual auditing then the associated costs would be charged in addition. 4.7 For a quick reference to the steps necessary for LANB auditing see Annex 3. Page 5 of 15 4.8 Please ensure that attention is paid to the readability of the audit report submitted to NMO. Alternatively send the audit report typed in electronic format to notified.bodies@nmo.gov.uk. An electronic Protocol and audit form is available to download on our website at http://www.nmo.bis.gov.uk/content.aspx?SC_ID=526 Document Control Version No. 0.0 1.0 2.0 3.0 Date of change May 2001 January 2005 September 2007 December 2010 Substantive changes Original document MID included Update of forms New protocol to align with Decision 768/2008/EC Page 6 of 15 Annex 1 AUDIT CHECKLIST (Essential elements to be included within the audit) 1) Designation letter (review conditions) Designated name Local Authority/group of Local Authorities Personnel operating under designation Scope of designation Review scope and class of instruments Conformity assessment tasks Types of instrument / sub categories of instrument 2) Essential Requirements Sub-contracting arrangements Testing by others Calibration by others Core criteria in the directives (annex V NAWI article 12 MID) Met at time of application Met on a continuing basis Independence and Insurance 3) Quality system Manual Procedures Plans Where a Notified Body is formed of a group of Local Authorities, are they operating to a common quality system? 4) Standards Local standards, working standards, test weights, EEC Directive weights Calibration, EEC verification of weights and other standards Standards maintained in-house, hired-in, other arrangements Range of standards available 5) Verification TAC and TC where appropriate Assessment of conformity to type Declaration of Conformity Certificate of 1st stage verification (if applicable) Verification tests Recording of the results (It is especially important that test sheets are correctly completed). 6) Application of the marks Manufacturer i.e. CE marking and Green Metrology Sticker Approved Body i.e. Notified Body Number Certificate of Conformity 7) Competence Evidence of staff training and knowledge Assessment of competence to undertake EC verification Annex 2 Audit Report Cover sheet (only one cover sheet is needed per audit) LA Notified Body audited Audit Officer LA Notified Body No. Telephone No. of auditor Date audited Supporting Audit Report e.g. ISO 9000 or UKAS (See auditing Protocol 3.3) Title Number Auditor’s signature/date Print name …………………………….. Date ……………………………………. Signature of auditor ……………………………………………… Signature of Authority representative Print name …………………………….. Date ……………………………………. Signature of representative ……………………………………………… Agreed to carry out corrective action: Print name ……………………………… Job title ………………………………… Signature of responsible officer (LANB) …………………………………………….. Auditor Satisfied corrective actions have been signed off and supplied with evidence corrective actions have been completed. Print name …………………………….. Date ……………………………………. Signature of auditor ……………………………………………… Detail of activities Please use the audit checklist when conducting the audit ensuring all points are covered e.g. quality manual, procedures, plans or other documents Item reference 1) Designation Letter Designated name Scope of designation 2) Essential Requirements Sub-contracting arrangements Core criteria in the Directives being met Independence and Insurance 3) Quality System Manual Procedures Notes NC’s Item reference Plan Groups of LANB all operate from same QS 4) Standards Local & Working Standards, test weights, EEC directive weights Calibration Maintenance of Standards Standards maintained in house, hired in other arrangement Range of standards available Notes N/C’s Item reference 5) Verification TAC & TC Assessment of Conformity to Type Declaration of Conformity Certificate of 1st stage verification Verification tests Recording of results 6) Application of Marks Manufacturer i.e. CE marking Green M sticker Approved body Number Certificate of Conformity Notes N/C’s Item reference 7) Competence Evidence of staff training and knowledge Assessment of competence undertaken Witness verification Opportunities for Improvement Notes N/C’s Details of non-conformities page of Item Reference from activity sheet Level of nonconformity Description of non-conformity Proposed corrective action Auditor Signature Date corrective action completed Annex 3 EXAMPLES OF MAJOR/MINOR NON-CONFORMITIES From paragraph 3.7 of the Auditing Protocol Area/Activity audited EC Verifications Description of non-conformity Major/Minor nonconformity Equipment has not been correctly verified Major Test result sheet not correctly completed Major Incorrect markings placed onto instrument Major No procedure to cover Appeals in relation to verification activities Minor Procedure exists but not addressed within QS for EC verification of NAWI/MID Minor Procedure exists however where refused submitter not made aware of right to appeal Minor No requirement within the procedure for the issue of C of C Major In procedure but no C of C’s have been issued against any of the EC verifications carried out Major Individual case of C of C not issued Major No training record in place for a member of staff performing EC verifications Major Training activity non-existent on all training files Major Training activity for member of staff not included on training record Minor Competence Staff unable to competently demonstrate verification testing Major Internal Audits No procedure or audit programme in place Major Procedure/programme in place, no audits conducted Major Not identified clearly Major Structure out of date or not accurate Major Individual Local Authorities within the group not working to a common QS Major Appeals Certificates of Conformity (C of C) Training Records Organisation Structure Joint Arrangements Opportunities for Improvement The aim of this is to allow the auditor scope to offer the authority, group suggestions for areas that might be improved upon. These will not go against the overall assessment, however allows the auditor to point out those areas that perhaps are not so serious to be awarded a major or minor nonconformity but are noteworthy to the auditing process.