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Surveillance and Reassessment

PUBLIC PROCEDURE GHG-PR-716 Issued: 2011-1-18, Revision: 0

References ANSI-TP-001: Statement of Conflict of Interest, Confidentiality and Compliance with ANSI Accreditation Policies and Procedures
ANSI-TP-001 Electronic Version: Statement of Conflict of Interest, Confidentiality and Compliance with ANSI Accreditation Policies and Procedures
GHG-FR-704: Application for Accreditation of Validation/Verification Body under ISO 14065
GHG-FR-705: ANSI Accreditation Criteria Checklist for Evaluation of Third Party GHG Validation/Verification Bodies
GHG-FR-707: VVB Surveillance Self-Assessment For GHG Program
GHG-FR-708: Application for Extension of Accreditation Scope for Validation/Verification Body under ISO 14065
GHG-FR-720: GHG Initial Assessment Report
GHG-FR-739: ANSI Witness Assessment Report on Organizational Verification
GHG-FR-742: ANSI Witness Assessment Report on Project Validation and / or Verification
GHG-PR-706: ANSI GHG Validation and Verification Body Accreditation Scoping Policy
GHG-PR-715: Application and Initial Assessment Process
GHG-PR-719: Conditions for Granting, Maintaining, Extending, Reducing, Suspending, and Withdrawing Accreditation
GHG-PR-722: Fees – GHG Program
Contents
1Objective
1.1The objective of this document is to establish the procedures for surveillance, reassessment and follow-up visits on the accredited greenhouse gas verification / validation bodies (V/VBs).
2Definitions
2.1V/VB: greenhouse gas validation / verification Body.
2.2GVAC: Greenhouse Gas Validation / Verification Accreditation Committee.
2.3CORRECTIVE ACTION: action taken to eliminate the cause(s) of a detected nonconformity. Corrective action is taken to prevent recurrence.
2.4PREVENTIVE ACTION: action taken to eliminate the cause(s) of a potential nonconformity. Preventative action is taken to prevent occurrence.
3Continuing Accreditation (Surveillance)
3.1Accredited V/VBs shall undergo surveillance during the first and second years after the year of their initial accreditation or reaccreditation.
3.1.1It is recommended that the first surveillance be carried out no later than 12 months from the date of initial accreditation or reaccreditation. The preferred interval for subsequent surveillance visits is 12 months. During the third year the V/VB shall undergo reassessment and reaccreditation as described in section 4 below.
3.1.2ANSI may decide to conduct surveillance visits out of sequence and without prior notice or with short notice if a complaint is received regarding the performance of the V/VB.
3.2The Purpose of Surveillance
3.2.1The purpose of annual surveillance is to:
a)determine that the V/VB continues to operate in accordance with ANSI requirements and any other applicable GHG program specific requirements;
b)determine if the V/VB continues to operate in accordance with the its own documented management system;
c)assess changes in personnel and personnel competency for the activities and sectors in which the V/VB operates including assessing competence for extensions of scope.
3.3Surveillance Forms
3.3.1At least three months prior to the V/VBs initial accreditation anniversary date, ANSI GHG Program staff shall make the required annual surveillance self-assessment report form GHG-FR-707 and the GHG-FR-705 checklist available to the V/VB and inform the V/VB of the due date for submission of these forms.
3.3.2The V/VB must return completed forms within the requested timeframe along with the required evidence/documentation and the annual fee per GHG-PR-722.
3.3.3The V/VB may request an extension or change to the proposed scheduled surveillance subject to approval by ANSI.
3.3.4ANSI shall review the forms for completeness making sure that all the appropriate questions have been answered and supporting documentation has been provided. If surveillance assessments include an application for extension of scope, the V/VB must notify ANSI of its intent to file such application and GHG-FR-708 and supporting documentation for the activities and sectors for which it seeks extension along with its surveillance deliverables.
3.3.5ANSI may request additional information and/or clarification from the V/VB. Additional documentation must be received promptly but no later than 30 days of the request. Significant delays in a V/VB’s submittal of the completed surveillance self-assessment form and/or the checklist may be grounds for suspension of the V/VB by the GVAC.
3.4Selection of the Assessment Team
3.4.1ANSI shall select candidates for the assessment team. The assessment team members shall be selected on the basis of competence and absence of potential conflict of interest. All selected assessors must have signed the ANSI confidentiality and conflict of interest form ANSI-TP-001.
3.4.2The same principles of conflict of interest that apply to selection of the assessment team for the initial assessment as stipulated in GHG-PR-715 shall apply to surveillance assessments.
3.4.3It is a common practice to assign surveillance to the same assessors who have conducted assessments on the subject V/VB in previous years; however, it is desirable to rotate the assessment team off during reassessment in order to have new assessors with fresh perspectives.
3.4.4The V/VB shall be provided with the resumes of the proposed members of the assessment team. The applicant may object to proposed team members based on perceived or actual conflict of interest within 10 days in which case ANSI staff shall select new candidate(s). Absence of the applicant’s objection within the 10 day period shall be interpreted as acceptance of the proposed assessment team.
3.4.5ANSI shall communicate the details of the surveillance assignment to the assessment team. ANSI shall ensure that assessors receive copies of forms GHG-FR-707 and GHG-FR-705 and any other documentation from completed assessments. Results of a completed internal audit shall be assessed during surveillance assessments.
3.5Document Review
3.5.1The assessors shall review the surveillance documentation and may request additional information from the V/VB. V/VBs shall provide the additional information within the timeline communicated by the assessors.
3.5.2If assessors are in disagreement on any issue related to the surveillance documents or are unsure as to how to proceed, they shall seek guidance of ANSI staff who in turn may request the involvement of the GVAC Evaluation Task Group (ETG).
3.6Onsite Assessment
3.6.1Assessors shall prepare an assessment plan including the sites to be assessed. This assessment plan shall be based on the results of the review of the GHG-FR-707 and GHG-FR-705 and shall take into other factors including but not limited to:
a)other accreditations held by the V/VB;
b)applications for extension of scope submitted by the V/VB;
c)organizational changes, acquisitions, mergers or divestitures;
d)any complaints received against the V/VB;
e)GHG program warning notice letters or validator/verifier suspension; and
f)volume of work.
3.6.2Onsite surveillance assessments shall be conducted by the ANSI assessors in the same manner and using the same principles that apply to onsite assessments during the initial assessment for the GHG Program. ANSI may choose to conduct the assessment or part of the assessment remotely based on past performance and consideration of the factors referenced in clause 3.6.1 above.
3.7Requirements for Annual Surveillance Witness Assessment
3.7.1The assessment team shall notify the V/VB of the activities, sectors and timeframes required for witness assessment. This may include the specific GHG program, project type and validation/verification body team members to be witnessed. V/VBs shall inform ANSI of the required types of verifications / validations to be witnessed using GHG-FR-740. Failure to notify ANSI and allow for the opportunity for ANSI to witness the V/VB may result in suspension.
3.7.2The following approach shall serve as guidance for required witness assessments during surveillance:
a)if the V/VB is accredited for verification of GHG assertions at the organization level a minimum of one witness assessment shall be conducted during the surveillance cycle. ANSI may choose to increase the number and type of witness assessments or to conduct a witness assessment every other year based on the performance of the V/VB during the surveillance period and factors referenced in 3.6.1. During years when a witness assessment is not conducted, ANSI shall perform a detailed document review of a completed verification. This review shall be documented in the office assessment report.
b)if the V/VB is accredited for validation and/or verification of GHG assertions at the project level a minimum of one witness assessment shall be conducted during the surveillance cycle. ANSI may choose to increase the number and type of project level witness assessments based on the performance of the V/VB during the surveillance period and factors reference in 3.6.1.
3.7.3Witness assessments shall be conducted by the ANSI assessors in the same manner and using the same principles that apply to witness assessments during the initial assessment.
3.7.4Witness assessment for activities and sectors included in application for extension of scope shall be carried out in accordance with GHG-PR-706: ANSI GHG Validation and Verification Body Accreditation Scoping Policy. Witness assessments conducted to satisfy such requirements may be considered to fulfill the annual surveillance requirements described above.
3.8Report and Continuing Accreditation
3.8.1At the conclusion of the assessment, the ANSI assessment team shall hold a closing meeting with the V/VB’s representatives. At the closing meeting, the ANSI assessment team shall present its findings identified during the surveillance and requirements for submitting corrective actions plans, informing the applicant of the appeals process. The team’s observations on areas for possible improvement (OFIs) shall also be reported; however, consultancy shall not be provided.
3.8.2In those cases where the ANSI assessment team cannot reach a conclusion or consensus about a finding, the team shall refer back to ANSI staff for clarification.
3.8.3The assessors shall upload in ANSICA a surveillance report using form GHG-FR-720 within 30 days of the completion of the last assessment related to the surveillance cycle of the V/VB. ANSI staff shall review the report, request clarification or revision to the reports before finalizing and providing the V/VB access to the reports for reference and comment. ANSI shall consider any comments submitted by the V/VB and edit the report as appropriate. The report shall include statements on continued conformance of the V/VB with the standard as well as all identified nonconformities (NCRs).
3.8.4The assessors shall also submit applicable witness assessment report(s) using GHG-FR-739 or GHG-FR-742.
3.8.5If any NCRs have been identified, the V/VB shall be requested to provide a corrective action plan and implementation target date within 30 calendar days from the date of the NCRs. If a corrective action plan is not posted within 30 calendar days ANSI staff may ballot suspension or reduction of scope to the GVAC.
3.8.6The V/VB implementation target date for proposed corrective actions is subject to the approval of ANSI. If corrective action is not posted within the approved timeline or if the proposed corrective action fails to sufficiently address the NCRs, ANSI may ballot suspension or reduction of scope to the GVAC. ANSI may also require that V/VBs provide ANSI with progress reports on the status of corrective actions.
3.8.7The GVAC does not explicitly vote for continued accreditation during surveillance. ANSI staff may convene the ETG to review the results of surveillance at the discretion of ANSI staff. ANSI staff shall consider the following actions as necessary to determine if an ETG review and action is necessary:
a)suspension of other accreditations held by the V/VB;
b)organizational changes, acquisitions, mergers or divestitures;
c)complaints received against the V/VB;
d)legal action brought against the accredited V/VB;
e)GHG program warning notice letters or validator/verifier suspension;
f)NCRs issued during surveillance or witness assessments.
3.8.8The ETG may, as a result of its review, recommend follow-up assessments or may recommend suspension of the V/VB accreditation to the GVAC. GHG-PR-719, section 6 details the reasons for GVAC suspension or withdrawal of accreditation. If the ETG recommends additional follow up assessments and/or witness assessments, the results of these assessments will be made available to the ETG for review.
3.8.9If an extension of scope is included in a surveillance cycle, an ETG review shall be conducted and a recommendation on accreditation shall be balloted by GVAC in accordance with GHG-PR-715. ANSI staff may postpone GVAC action on a V/VB’s application for scope extension due to open NCRs or pending the outcome of follow-up assessments per clause 3.8.8 above.
3.8.10If during a witness assessment, ANSI identifies one or a series of significant NCRs in the validation, verification or reports of the V/VB, it shall bring the matter to the attention of the ETG. If the ETG determines that a V/VB is not in conformance with one or more requirements of ANSI or a GHG program, it may recommend suspension to the GVAC.
3.9Follow-up visits
3.9.1ANSI may conduct follow-up visits to V/VB in order to verify evidence of implementation of corrective actions or in other circumstances requiring additional assessment.
3.9.2Customarily, follow-up visits are conducted by the same assessor(s) who conducted the original visit. Otherwise, assessors must be confirmed by V/VB as in clause 3.4.2.
4Reassessment
4.1An accredited V/VB shall undergo full reassessment every three years, prior to expiry of its accreditation.
4.2The reaccreditation process follows the application and initial assessment process almost entirely with the following exceptions:
a)no preliminary application is required;
b)no application fee is due. Instead, the annual fee per GHG-PR-722 must be submitted along with the GHG-FR-705;
c)the assessment team shall consider the results of previous assessments in planning for and conducting the reassessment;
d)if an accredited V/VB is issued NCRs during the reassessment which are not closed within the timeframe required by the GVAC, the GVAC, per GHG-PR-719 may vote to extend the validity date of accreditation for the VVB for a limited amount of time pending the satisfactory closure of the NCRs.

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