ISO 14001:2004 Environmental Management System Design ... · ISO 14001:2004 Environmental...

ISO 14001:2004 Environmental Management System Design Guidance and Timeline

for use by participants in the North Carolina

Environmental Stewardship Initiative

Version 1.1 September 20, 2006

Division of Pollution Prevention and Environmental Assistance N.C. Department of Environment and Natural Resources

1639 Mail Service Center Raleigh, NC 27699-1639

919-715-6500


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The North Carolina Department of Environment and Natural Resources’ Environmental Stewardship Initiative is designed to promote and encourage superior environmental performance by North Carolina’s regulated community. This voluntary program establishes incentives to stimulate the development and implementation of programs that use pollution prevention and innovative approaches to meet and go beyond regulatory requirements. One of the criteria for participation is implementation of an environmental management system. As staff support to the ESI, the Division of Pollution Prevention and Environmental Assistance (DPPEA) has developed the following EMS guidance materials and an associated timeline modeled on ISO 14001:2004 as a benefit to ESI participants to assist in meeting program criteria. The purpose of this tool is to assist facilities in organizing an approach to EMS design. The tool covers the majority of EMS elements but does not address every requirement in ISO 14001:2004. It is recommended that an organization use ISO 14001:2004 and ISO 14004:2004 as its main reference documents for EMS design and implementation. Work on some elements may begin in one step and be finalized in a later step. The guidance and timeline have been organized in order to assist facilities to:

1. Develop an understanding of the organization’s current environmental management program and build on these existing efforts.

2. Design the core elements that require the greatest input from the EMS team in the beginning of the process.

3. Allow the EMS team to develop an understanding of the link between the core elements of the EMS before establishing document guidance and control requirements.

The EMS team is comprised of individuals from a cross-section of the organization with broad knowledge of facility operations. The EMS coordinator serves as the EMS “champion” and may work alone or with one or two other individuals to set meetings, complete unassigned tasks and keep the process moving between team meetings. In addition, four modules have been developed to provide training on specific EMS elements. Modules align with steps outlined in this guide and are designed to be used in conjunction with it. The four modules are:

Identifying and ranking environmental aspects Operational control and monitoring and measurement Establishing objectives and targets / environmental management programs Corrective and preventive action, internal EMS audits and compliance with legal and other

requirements Contact Norma Murphy, DPPEA, 919-715-6513 or [email protected] for more information on module training classes.


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Suggested Steps for EMS Design and Timeline

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Management Review Board Meetings *

EMS Team Meetings Gap Analysis ** Step 1: Roles and Responsibilities and Scope Step 2: Initial Environmental Review (Legal & Other) Step 3: Aspects, Policy and Impact Analysis Step 4: Operational Control & Emergency Response Step 5: Monitoring and Measurement Step 6: Objectives, Targets and Programs Step 7: Documentation and Document Control Step 8: Corrective and Preventive Action Step 9: Competence, Training and Awareness Step 10: Compliance and Records Step 11: Communications and Management Review Step 12: Internal Auditing Note: Click on an EMS element above to move forward to that step in the document. * First internal audit with results reported at next management review board meeting ** First MRB meeting covering all requirements of ISO 14001:2004


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Summary of EMS Team Meetings by Week -- 10 Month Timeline for EMS Design Week Team

Meeting Activities

1 Identify EMS coordinator and other key roles. Establish EMS scope. 2 1 Collect information for initial environmental review, legal and other requirements.

Meet in 3 weeks. 5 2 Develop process flow diagram and aspect and impact list. Meet in 3 weeks. 8 3 Draft policy. Develop significance criteria. Meet in 3 weeks. 11 4 Determine significance. Meet in 1 week. 12 5 Begin operational control and emergency response planning. Meet in 3 weeks. 15 6 Develop monitoring and measurement program. Meet in 3 weeks. 18 7 Set objectives and targets. Meet in 2 weeks. 20 8 Develop O&T management programs. Meet in 2 weeks. 22 9 Begin document control. Meet in 3 weeks. 25 10 Develop corrective and preventive action process. EMS coordinator develops training

schedule and competence evaluation. Meet in 3 weeks. 28 11 Review training and competence process. EMS coordinator develops process for

evaluation of legal and other requirements. Meet in 4 weeks. 32 12 Develop communication and management review process. Establish next meeting

based on ongoing EMS implementation needs. 36 EMS coordinator develop internal audit program. 38 EMS “live.”


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Step 1 Roles and Responsibilities and Scope (4.1 and 4.4.1) A successful organization has the commitment of top management to establish or improve its environmental management. Development and ongoing implementation of the EMS must have this support. It is recommended that the organization obtain copies of 14001:2004 and 14004:2004. Information on purchasing the standards may be found at http://www.p2pays.org/iso/emsisofaq.asp#faq9. Complete Step 1 prior to first team meeting. I) Review organizational structure and select initial roles and responsibilities (ISO 4.4.1) for:

- An EMS coordinator who will: o Lead the design and implementation of the management system in conformance with ISO

14001:2004. Some initial steps include: - Determining if the organization will use an EMS software program or consultant. - Organizing an EMS team who will assist in the design and implementation of the

EMS. This team should include representatives from a cross-section of the organization that are knowledgeable of facility operations. In addition, the team needs to represent all key areas and be comprised of decision-makers for each area to facilitate timely EMS implementation. Set team meetings and track team progress.

- Planning for integration with a quality management system or health and safety management system such as ISO 9000 or OHSAS 18000 if appropriate.

- Developing an implementation schedule including reports to top management on progress of EMS design and implementation.

- Considering a kick-off meeting or memo to all staff regarding the implementation project.

o Upon implementation of the EMS, assure the ongoing scheduling and reporting on the EMS at management review board meetings; ensure corrective and preventive action process is functioning; assure completion of internal and external EMS audits and internal compliance audits; and arrange ongoing training of all employees about the EMS policy and EMS awareness.

- A management representative for each organizational unit (i.e. sections, departments, etc.) who will: o Assure the EMS is maintained and resources allocated o Report to top management or top management representative on the performance of the EMS

at defined intervals once the EMS is implemented (4.6 Management Review). o Often, the management representative and the EMS coordinator are the same person.

- A document/record controller(s) who will: o Assure that all controlled documents and environmental records are maintained according to

the EMS document control requirements (ISO 4.4.5) and environmental records requirements (ISO 4.5.4) once these procedures are established internally.


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II) Define scope (4.1) - Set specific boundaries to which the EMS will apply. All activities, products and services within this

boundary should be included in the EMS. Write a description of the EMS scope. - Although the EMS scope is determined during this step, an organization may continue to revise its

EMS later in the development phase or over time. III) Identify external training needs and resources for key personnel

- Lead auditor training or at minimum internal auditing training is strongly recommended for the EMS coordinator. Even if this person is not involved in auditing, the training provides an understanding of the process and audit reports.

- Identify mentor organizations whose EMS coordinator can provide guidance during design and implementation.

- Top management representative should attend some level of training on the intent and structure of the ISO 14001 EMS or have discussions with top management of mentor organization(s) on EMS process.

- EMS coordinator and key personnel should consider attending internal or third-party audit of mentor organization.

IV) Communicate top management support to EMS team

- Top management support is key to successful EMS implementation. A kick-off meeting with EMS team members and top management demonstrates commitment and support for and interest in EMS efforts. A letter to EMS team members from top management may also show support for EMS efforts.

III) Schedule registration audit

- If registration to ISO 14001 is planned, consider when this will be scheduled as the EMS is developed. Coordination of facility and auditor’s schedule may require advance notice.

- A pre-registration audit or readiness review is highly recommended to identify any key issues prior to the actual registration assessment.

- Consider registrar attributes prior to selection of a registrar. This may include experience, fees, surveillance schedule, what they expect to see for documented procedures, how non-compliance is handled, etc.

See Appendix F for a list of questions to consider in registrar selection. Additional resources:

“Getting Started” flow chart taken from Environmental Management Systems: An Implementation Guide for Small and Medium Sized Organizations, NSF International, 2001 - http://www.p2pays.org/iso/files/ems.pdf Two slides show presentations from facilities on deciding whether to integrate an EMS with a

quality management system - http://www.p2pays.org/iso/integrate.asp Listing of EMS training and workshops - http://www.p2pays.org/iso/training.asp

Back to Timeline

http://www.p2pays.org/iso/files/ems.pdf

http://www.p2pays.org/iso/integrate.asp


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Notes:


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Step 2 Identify Legal and Other Requirements and Initial Environmental Review (4.3.2) Team Meeting 1: Assign responsibilities at first team meeting and provide approximately three weeks to collect information. The initial environmental review serves to identify the parts of an EMS already in place in an organization as well as collect information for use in later steps. This information will be useful in addressing a number of EMS elements. A more comprehensive job done now will ease work later. I) Identify legal and other requirements to which the organization subscribes (4.3.2):

- List federal, state and local environmental regulatory requirements. In addition to permits, consider requirements for possible local landfill bans (cardboard), medical waste (such as from nursing stations), septage and proper electronics disposal.

- Identify “other” programs the facility has committed to participate in that have environment requirements. This may include membership in voluntary programs such as DENR’s Environmental Stewardship Initiative; EPA’s WasteWise or Performance Track; business programs such as Responsible Care or the International Chamber of Commerce Sustainability Principles; corporate or supplier requirements, etc.

- For both legal and other requirements, determine the following and consider documenting this information:

o Location of guidance documents and resources related to each requirement o Monitoring requirements related to requirements o Date due and frequency of reporting o Documents required to be maintained and location o Records required to be maintained and location o Current schedules and tracking of training related to environmental requirements (what it

covers, when training occurs, who is trained, who trains, where are records) o Who is responsible for maintaining records

- List work performed by contractors at your facility requiring environmental certification or permitting. (ex. Hazardous waste transportation; heating, ventilation and air conditioning repair; pesticide application; construction; etc.)

II) Collect data

- If available, a flow chart or diagram of facility processes. - List facility history of violations for the past five years, any ongoing site remediation/monitoring

activities and any previous major violations. - Collect data on the amount and type of waste produced or discharged including frequency and

hazardous characteristics. - Collect billing information on raw material purchasing, energy costs, water costs, etc. - Identify control equipment and any related operating manuals, calibration requirements, etc. - Identify existing work instructions or standard operating procedures related to controlling or

preventing generation of waste streams including those developed for contractors. (4.4.6)


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II) Identify emergency response procedures and recent events (4.4.7) - Obtain copies of existing emergency response procedures. - Collect information on emergencies, accidents or spills that had an environmental impact. - Identify any past emergency drills or practice events and results.

III) Identify external concerns regarding impacts to the environment

- List any identified local environmental concerns related to the facility such as location in an ozone non-attainment area, water restrictions, truck traffic, noise, etc.

- Collect information on any external complaints. Use tables in Appendix A to assist in compiling information. Additional resources:

Links federal and N.C. legal requirements at http://www.p2pays.org/iso/legal.asp . Back to Timeline Notes:

http://www.p2pays.org/iso/legal.asp


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Step 3 Environmental Aspects, Policy and Impacts Analysis (4.2, 4.3.1) An environmental aspect is any element of an organization’s activities, products, and services that can interact with the environment. These may or may not be regulated. An environmental impact is any change to the environment, whether adverse or beneficial, wholly or partially resulting from an aspect. The resulting significant aspects are the foundation for much of the EMS. Only a facility’s staff can determine how to assess significance. This element is considered one of the most difficult to complete in designing an EMS. Team Meeting 2: Review environmental information to develop team’s knowledge and awareness of issues. Assign responsibilities for the identification of activities, products and services within the EMS scope and associated aspects and impacts and meet in three weeks. Team Meeting 3: Review listing of aspects and impacts. Draft environmental policy. Develop ranking criteria and walk through ranking an aspect and related impact. Apply ranking criteria and meet in three weeks to finalize ranking list. Team Meeting 4: Finalize ranking of aspects and impacts. Determine significant aspects. Set next meeting date for following week. I) Develop documented aspects and impacts list (4.3.1)

- List activities, products and services within the EMS scope. Refer to existing flow charts or process flow diagrams. More detailed information can be found in ISO 14004:2004, 4.3.1 Environmental aspects.

- List associated actual and potential aspects and impacts for each activity, product and service. An aspect may have more than one environmental impact. List aspects where the organization has fiscal, organizational or contractual control. Make sure to list positive environmental impacts. Consider listing any observations, such as related management controls, along with each aspect to assist with later review.

- Include aspects and impacts from normal and abnormal operating conditions including clean-up, maintenance, planned shutdowns, emergency situations and foul weather.

- Include aspects and impacts from planned or new developments, new or modified activities (i.e. construction), products and services.

- Consider grouping similar aspects. However, an organization may keep aspects listed separately that have different impact levels. For example “water use” may be an aspect across the facility or listed as separate aspects in specific departments to account for greater use in certain areas.

- Write process summary to identify aspects and impacts. II) Draft environmental policy (4.2) ‐ Must include the three major commitments: continual improvement, prevention of pollution and

compliance with applicable legal requirements and other requirements that the organization subscribes.


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‐ Must be available to the public and communicated to all employees and to those working on behalf of the organization.

‐ As appropriate, circulate for input and feedback. ‐ Environmental policy helps guide setting significance criteria and setting objectives and targets. Some

facilities choose to begin EMS design with creating a policy statement prior to aspects development. III) Develop a ranking system, rank aspects and determine significance ‐ Determine whether to use quantitative or qualitative ranking criteria (or a combination) and develop

associated definitions. Facility may consider weighting specific criteria relative to others. ‐ Consider using a limited number of criteria to gain experience and confidence without being overly

complex. If using a quantitative scheme, consider a limited scoring range for easier use and understanding. Make sure aspects with positive impacts can be determined significant.

‐ Develop definitions for each criteria used to determine significance. For instance, in a category of “probability” define high, medium and low. Apply criteria and assess need for any modifications. Ranking system should be repeatable for future aspect listings.

‐ The results of using the ranking system should reflect the facility’s greatest environmental concerns. ‐ Review prioritized list for a “reality check” and finalize ranking. Determine which aspects are

significant such as where the “cut-off” point will be or if an aspect scores high in any one category, it is deemed significant.

‐ The list of significant aspects will be used in o setting objectives and targets o developing operating procedures related to activities that have the potential to result in

significant environmental impacts and those related to identified significant aspects. Procedures shall be communicated to those working on behalf of the organization such as suppliers and contractors.

o assuring proper training and competence of appropriate individuals o development of key monitoring and measuring characteristics related to these actual or

potential impacts. - Write process summary to rank aspects and impacts.

See tables and information in Appendix B and C for developing lists and ranking criteria. Additional resources:

Comprehensive slide show presentation on aspects and impacts and ranking by Suzanne Sessoms at http://www.p2pays.org/ref/32/31049.pdf Discussion in ISO 14004:2004, 4.3.1 Environmental aspects

Back to Timeline Notes:

http://www.p2pays.org/ref/32/31049.pdf


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Step 4 Operational Control and Emergency Preparedness and Response (4.4.6 & 4.4.7) Team Meeting 5: Review list of identified significant aspects and assign responsibility for the development of operational procedures/work instructions. Identify potential adverse impacts that could result from emergency situations or accidents and assign responsibility for emergency procedures development. Set time frame for completing work instructions and procedures depending on volume. Meet in three weeks. I) Identify and document operations associated with significant aspects and ensure they are carried out under specified operating conditions

- Operational control may be a work instruction or standard operating procedure, checklist, a sign such as “cardboard only” or training.

- Identify operations associated with significant aspects where absence of a documented procedure could lead to deviation from the policy or identified objectives and targets (O&T will be discussed in Step 6).

- For those operations needing a documented procedure, review work instructions collected during initial environmental review and update if lacking operating criteria.

- Determine additional work instructions needed and prepare accordingly. - Include operating criteria in procedures for both normal and abnormal conditions. This should include

“what to do” and “how to do it.” Procedures should be a part of employee training as they provide information on how to do the job and the importance of following procedures. Employee training is covered in Step 9.

- Determine how to notify suppliers and contractors of proper operating procedures. - Consider including in the work instruction actual or potential environmental impacts associated with

the work and environmental consequences of departure from the procedure. [4.4.2 b) and d)] II) Identify existing and needed forms and checklists associated with work instructions

- Forms and checklists must be included in the document control system. This is discussed in Step 7. III) Identify existing and needed emergency response procedures (4.4.7)

- Identify possible incidents that could cause accidental emissions, discharges and specific environmental or ecosystem impacts.

- Review emergency response procedures collected during initial environmental review to identify any deficiencies and any situations that lack procedures.

- Update or write procedures that include the proper mitigation and response actions to minimize adverse environmental impacts.

- Set schedule to test procedures where practicable. - Ensure suppliers and contractors can access emergency contact information and procedures if

appropriate. - Document training requirements and completion of training.


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IV) Complete gap analysis and report to top management on progress of EMS - Compare existing programs and work completed against each element of the standard, element-by-

element. - Summarize progress to date on completing and implementing EMS design requirements - Report to top management results of progress.

Additional resources:

Sample gap analysis tools to assist in tracking EMS progress can be found at http://www.p2pays.org/iso/samplegap.asp. Please note that these tools were developed for use with ISO 14001:1996. They may still be useful guidance tools to track design and implementation progress.


http://www.p2pays.org/iso/samplegap.asp


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Step 5 Monitoring and Measurement (4.5.1) The results of monitoring and measurement are used to identify both successes as well as areas needing improvement in the EMS. Team Meeting 6: Review progress of completing work instructions and emergency response procedures. Establish the key characteristics that can have a significant environmental impact and assign responsibility for identifying the monitoring and measuring equipment, methodologies and associated calibration requirements. Finalize environmental policy. Meet in three weeks. I) Establish key characteristics

- The key characteristics are those things that provide management with information on how the facility is performing related to its significant aspects, objectives and targets and goals for continual improvement (Objectives and targets will be discussed in Step 6). A facility tracks a number of items and not all are key characteristics. Some new measures may need to be established to effectively report progress on the items listed above. Key characteristics provide management with information to assess how well the EMS and related elements are performing. Information gathered may provide guidance on where to set new objectives and targets or other needed system improvements.

- In this step, the team should identify key characteristics related to its significant aspects. In step 6, the team will establish performance indicators for objectives and targets that will be incorporated into the monitoring and measuring system. Some of these performance indicators for objectives and targets may be the same as the key characteristics identified in this step and some may be new.

- Measuring equipment related to these key characteristics should be identified, proper operating procedures applied and if necessary calibration requirements established. Identify and retain associated records.

II) Identify existing and needed forms and checklists associated with key characteristics

- This may include calibration schedules and updates to training requirements. III) Finalize environmental policy (4.2) ‐ Must include the three major commitments: continual improvement, prevention of pollution, and

compliance with applicable legal requirements and other requirements that the organization subscribes.

‐ Must be approved by top management. Back to Timeline Notes:


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Step 6 Objectives, Targets and Management Programs (4.3.3) Team Meeting 7: Review progress of completing work instructions and emergency procedures. Establish objectives and targets with input from the organization’s top management. Meet in two weeks. Team Meeting 8: Review progress of completing work instructions and emergency procedures. Develop programs to accomplish objectives and targets including designating responsibility at relevant levels and functions of the organizations and the means and timeframe to achieve them. Meet in two weeks. I) Establish objectives and targets with input from top management

- Review information collected in the initial environmental review for ideas on where to set improvement goals.

- Consider the facility environmental policy (including commitments to prevention of pollution and compliance with legal and other requirements and continual improvement).

- Consider legal and other requirements; significant environmental aspects; technological options; financial, operational and business requirements; and views of interested parties.

- Consider establishing initial goals that are achievable and provide the organization with the opportunity to develop an understanding of the objective and targets planning process.

- Initial goals may be planning or study goals that are used to develop a performance baseline and possible options for improving performance. Goals may address both improvements to performance and the EMS system. A goal may be to maintain a level of performance such as zero spills.

- Consider setting some goals that apply across the facility. This provides a tangible connection to the EMS for employees, spreads responsibility for success across departments, improves buy-in and builds commitment.

- Identify performance indicators that are measurable where practical in relation to objectives and targets. These performance indicators may be added to the key characteristics of a facility’s monitoring and measurement program.

- Communicate progress toward objectives and targets at all levels across the facility. - Consider linking achievement of environmental goals to established business goals and rewards. - Once the EMS is established, look to set future quantitative goals with targets on leading indicators

rather than lagging indicators and on input rather than output areas and goals based on the pollution prevention hierarchy. Consider normalizing goals.

- Write process summary to develop objectives and targets. II) Develop management programs associated with objectives and targets

- Establish the timeframes, means and responsibilities at relevant levels or function of the organization to ensure objectives and targets are achieved.

III) Document objectives and targets at relevant functions and levels within the organization


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IV) Establish frequency of review related to progress of objectives and targets for top management

- A facility may not always meet its set objectives and targets due to changing business circumstances or other reasons. The EMS is a living system and can be updated, including its improvement goals.

See sample objectives and targets in Appendix D. Back to Timeline Notes:


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Step 7 Documentation and Document Control (4.4.4 & 4.4.5) Team Meeting 9: Develop document control process and apply to existing procedures. EMS coordinator may want to draft document control process and procedure template with assistance from document controller and management prior to the meeting. Assign responsibility for integrating document control process into written procedures. Allow two months to complete integration. Meet in three weeks. I) Establish document control process

- Clarify levels of procedures (i.e. Level 1 - policy, Level 2 - implementing procedures, Level 3 - operating procedures, work instructions, Level 4 - forms and associated references).

- Identify and develop information required on documents to provide control. Ensure documents: Are approved for adequacy prior to use (i.e., signature of management), Are readily identifiable (e.g., numbering system or title), Have established review frequency to ensure continued adequacy, Indicate changes and current revision status (i.e. revision number and date), Are available at points of use, Show linkage to relevant documentation, Are controlled to prevent unintended use of obsolete documents, Remain legible, and Consider how to identify and control external reference materials.

- Develop procedure template with control information to be used in developing controlled procedures (template header). At a minimum, document control must include document title, revision date, and by whom the document is approved.

- Consider development of template for level 2 and 3 procedures that includes additional information within procedure to assist in meeting ISO 14001 requirements:

Consider including purpose and scope for procedure, Require listing associated documentation and references to equipment in procedures, List roles and responsibilities associated with procedure, List benefits of following procedures as well as environmental consequences of not following

procedures, and Provide format for documenting revision language over life of document.

II) Develop document control procedure that incorporates the information above

- Assign responsibility for control of documents. - Consider establishing a document control form that tracks the most recent versions of EMS related

documents, their location and retention times of obsolete documents.


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III) Apply document control and procedure templates to Level 2 and 3 procedures - Using description of process from step 3, Aspects and Impacts (4.3.1), consider writing procedure

that describes: How the organization assesses its aspects and impacts, How the organization determines significance, How it identifies the aspects and impacts of new or modified activities products or services, What frequency is required to assure that aspects and impacts have been kept up-to-date, Who has responsibility for these activities, How to show linkage to other key EMS elements such as legal and other requirements, training

needs, operational controls and objectives and targets, and Reference and create associated forms.

- Using information gathered in step 2, Legal and Other Requirements (4.3.2), consider writing procedure that describes:

Who is responsible for keeping up-to-date on legal and other requirements, What information is needed to keep up-to-date on legal requirements and access to it, The linkage between legal and other requirements and an organization’s aspects (determining

which are applicable to the organization’s activities and related aspects), and Any reference forms used. Forms may list current legal and other requirements, reporting

dates, frequency of reporting and other information that assists in maintaining the commitment to compliance.

- Using description of process from step 6, Objectives, Targets and Management Program (4.3.3.), consider writing procedure that describes:

How the organization establishes objectives, targets and programs, To whom and what frequency the status of these objectives and targets are reported, Who is responsible for ensuring these activities take place and track progress, and References to forms listing objectives and targets and programs.

- Resources, Roles, Responsibility and Authority (4.4.1), consider writing procedure that describes: How the key environmental management roles, responsibilities and authorities are defined and

communicated to all persons working for or on behalf of the organization, and How the EMS coordinator oversees the EMS establishment, implementation and maintenance

including reporting to top management on system performance and recommendations for improvement.

- Operational Control (4.4.6), consider writing procedure that describes: The need to develop operating procedures or work instructions and associated forms related to

new and existing significant aspects, The process for communicating requirements to those working on behalf of the organization, A template to be used in the development of any work instruction to assure consistent

information, and A link between work instructions and associated significant aspects.


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- Emergency Preparedness and Response (4.4.7), consider writing procedure that describes: The process for identifying potential incidents and how it will respond to those that can have

adverse impacts on the environment, A periodic review and testing process with subsequent revision to procedures when necessary,

particularly after a “real” emergency situation, and Those who are responsible for ensuring these activities take place.

- Monitoring and Measurement (4.5.1), consider writing a procedure that describes: How the organization monitors key characteristics of its operations that can have a significant

impact including sources of information, frequency and measurement method, Calibration requirements, How it documents information to monitor performance and progress on objectives and targets,

and Who is responsible for ensuring these activities take place.

IV) Write a description of the main elements of the EMS, their interaction, and reference related documents {4.4.4(c)} V) Complete gap analysis and report to top management on progress of EMS Back to Timeline Notes:


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Step 8 Corrective and Preventive Action (4.5.3) Team Meeting 10:Review document control process integration and make any adjustments. Develop process for reporting and responding to corrective and preventive actions. EMS coordinator may want to draft process for reporting and responding to corrective and preventive actions with input from management prior to the meeting. Meet in three weeks. I) Develop corrective and preventive actions process (4.5.3)

- A non-conformance is a deficiency where implementation is not consistent with the EMS description or the system does not meet the EMS criteria.

- Corrective and preventive action allows for ongoing improvement of the EMS and enhanced environmental performance.

- Establish corrective and preventive action form or forms to: Document event information (who, when, where), Document the identification of actual or potential non-conformances, Document the investigation of root causes, Document assessment if applicable in other locations, Document the level of magnitude the findings rise (major, minor, opportunity) to assure

appropriate response, Document corrective actions taken to avoid reoccurrence including schedule, Document preventive actions taken to avoid occurrence including schedule, and Document that a review of effectiveness of corrective and preventive action took place.

- Determine roles and responsibilities related to each section of the forms and how forms will be handled and how changes to written work instructions will be recorded.

- Consider development of a form to summarize actions for reporting to top management.

II) Develop procedure providing guidance on non-conformances, corrective and preventive actions

- Document process and responsibilities for handling corrective and preventive action reports referring to processes developed in Step 7.

- Define the process for evaluating the need for action(s) to prevent non-conformities and implementing appropriate actions.



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Step 9 Competence, Training and Awareness (4.4.2) EMS coordinator: Prior to Team Meeting 11, work with management to develop a procedure for evaluating competence of those following work instructions and tracking of training. Schedule general awareness training (Policy and basic EMS overview) and targeted training related to significant aspects within the next two months. Team Meeting 11: Continue work on and complete integration of level 2 and 3 documents and forms. Review the development of reporting and responding to corrective and preventive actions and review plan for meeting training requirements and competence evaluation. Meet in four weeks. I) Develop procedure to identify and track training needs and evaluate competence (4.4.2)

- Identify the training needs of employees or persons working on behalf of the organization. Refer to operational control procedures developed in Step 4 and identify any related training needs. Document responsibilities. Training covers:

Importance of conformance with the environmental policy and requirements of the environmental management system, Individuals whose work activities have significant aspects that can result in actual or potential

impacts, and Needs related to legal and other requirements of the organization’s environmental aspects.

- Develop process and responsibilities for evaluating competence of employees or persons working on its behalf whose job activities have the potential to cause significant environmental impacts. This may be achieved via observation, questions from supervisor, written test or other means.

- Consider development of experience, competence and training needs for personnel performing specialized environmental management functions.

- Use process developed in Step 7 to write procedure. - Consider developing standard training sign-in form.

II) Schedule general awareness training and training for those who can have significant impacts

- General awareness training will include Policy and Overview of the EMS. Suggest including basic emergency response information as well. Document attendance and make plans to provide training to absent employees or contractors as appropriate. General training is for all employees, including top management.

- Training for persons whose activities can result in actual or potential significant impacts will require training on proper operating procedures, benefits of improved personnel performance and consequences of departure from specific procedures. Document attendance and make plans to provide training to absent employees or contractors as appropriate.


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- Provide information to contractors and suppliers on EMS awareness, emergency response and work procedures as appropriate. Verify training of contractors if legal requirements apply such as for HVAC repair, pesticide application, etc.



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Step 10 Evaluation of Compliance & Control of Records (4.5.2 & 4.5.4) EMS coordinator: Develop a procedure(s) for periodically evaluating compliance with applicable legal and other requirements and develop a procedure for environmental records with input from record controller. I) Develop procedure(s) for periodically evaluating compliance with legal and other requirements

- Develop instructions and responsibilities for evaluating compliance with legal and other requirements including frequency appropriate to the organization’s scale. Refer to document control template developed in Step 7.

- Consider an independent review. For a larger organization, this may be a corporate audit. - May want to develop two procedures (one for legal and one for other). - Information from assessments should be included in management review.

II) Develop procedure for control of records

- A record shows the history of what has happened and cannot be changed. A record differs from a document such as a work instruction that can be revised and describes intended action or provides guidance.

- Document process and responsibilities for identifying, storing, protecting, retrieving, retaining and disposing of environmental records. Records should remain legible, identifiable and traceable.

- Consider the development of a matrix to list environmental records and the location and retention requirements. If forms are used, ensure that these are controlled as part of the document management system developed in Step 7.

- Establish procedures on where, how, and how long records are kept. Back to Timeline Notes:


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Step 11 Communication and Management Review (4.4.3 & 4.6) Team Meeting 12: Develop a procedure(s) for internal and external communication and develop a procedure to describe the process of management review. Establish next meeting based on ongoing EMS maintenance needs. I) Develop procedure for internal and external communication

- Identify responsibilities and methodologies for communicating environmental information within the organization up to management and down to staff and persons working on behalf of the organization.

- Develop process for receiving, documenting and responding to relevant communications from external interested parties. Refer to document control template developed in Step 7.

- Record decision on external communication of significant environmental aspects. If organization chooses to communicate externally about its significant aspects, develop and implement a method to achieve this.

- Stewards in the ESI have committed to have a process for communication with the local community on program activities and progress toward performance goals that goes beyond the requirements of ISO 14001:2004. Examples of this type communication can be found in Appendix E.

II) Develop procedure for management review

- Document process and responsibilities for reporting on the progress of the management system to top management.

- Determine planned intervals that this information will be reviewed. - Reports should include information pertaining to results of:

internal audits, compliance evaluations of legal and other requirements, communications from external parties, the environmental performance of the organization, the extent to which objectives and targets have been met, the status of corrective and preventive actions, follow-up actions from previous management reviews, changing circumstances including developments in legal and other requirements related to its

environmental aspects, and recommendations for improvement.

- Management decisions should relate to possible changes to the policy, objectives and targets and other EMS elements consistent with a goal of continual improvement. Management review must include consideration of the continuing suitability, adequacy and effectiveness of the EMS.

- Determine how the management review shall be recorded and retained.


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See examples of external communication by Stewards to meet ESI program criteria in Appendix E. Back to Timeline Notes:


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Step 12 Internal Auditing (4.5.5) EMS coordinator: Develop a procedure for internal auditing and identify and train auditors (if necessary) and complete readiness audit. Information collected assists in determining overall EMS continuing adequacy, effectiveness and suitability. Each individual internal audit does not have to cover every EMS element but may instead cover all elements in time. I) Develop procedure for internal auditing

- Identify responsibilities and methodologies (criteria, scope, frequency) for the internal auditing program. Refer to document control template developed in Step 7.

- Establish planned intervals to Assure the EMS is in conformance with ISO and has been properly implemented and

maintained, and Provide information on results of audits to management.

- Consider results of past audits, organizational scale and other factors in setting an audit plan. - Consider the development of an audit report summary to cover areas and issues identified during audit. - Consider development of audit findings form to document findings that may require corrective or

preventive actions. - Determine whether internal or external auditors will be used. If internal auditors will be used,

establish training and competency requirements for auditors. - Establish objectivity and impartiality guidelines for the audit process.

II) Complete internal audit and report to top management Additional resources:

ISO 19011:2002 provides guidance on the principles of auditing, managing audit programs, conducting quality management system audits and environmental management system audits, as well as guidance on the competence of quality and environmental management system auditors. “ISO 19011:2002 - Guidelines for quality and/or environmental management systems auditing” http://www.iso.org/iso/en/CatalogueDetailPage.CatalogueDetail?CSNUMBER=31169&ICS1=13&ICS2=20&ICS3=10


http://www.iso.org/iso/en/CatalogueDetailPage.CatalogueDetail?CSNUMBER=31169&ICS1=13&ICS2=20&ICS3=10

http://www.iso.org/iso/en/CatalogueDetailPage.CatalogueDetail?CSNUMBER=31169&ICS1=13&ICS2=20&ICS3=10


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Appendix A

Initial Environmental Review

Examples of templates for collecting environmental information

Legal and other requirements and associated documents/ records

Monitoring requirements

Location Responsible party

Environmental training

Trainees Trainer How tracked Records location

Describe non-compliance

Cause of noncompliance

Date Environmental impact, if any

Equipment manuals/ operational procedures work instructions

Associated forms Calibration requirements

Responsible party

Location


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Appendix B #1

Sample #1 -- Aspect and Impact and Significant Scoring Form Use the following chart to list an activity and related aspects and impacts at your facility. Write the activity in Column No. 1. List as many aspects as you can for this activity. An aspect is an element of an organization’s activities, products or services that can interact with the environment including things such as raw materials, water and energy use, wastes and emissions. Write the aspects in Column No. 2. If the aspect is from normal operating conditions, list at the top portion of the chart. If the aspect is due to abnormal or emergency conditions, list at the bottom portion of the chart. In Column No. 3, put a (+) or (-) next to each aspect in Column No. 2 to indicate whether the aspect would result in a positive or negative change to the environment. In Column No. 4, list the environmental impact. Columns No. 5, 6, and 7 can be used for significance scoring of aspects and impacts. Add rows for additional aspects under normal or abnormal operating conditions as needed. 1. Activity __________ __________

2. Element that can interact with the environment (aspect)

3. (+) or (-)

4. Change to the environment resulting from aspect (impact)

5. Significance Criteria A. __________ B. ____________ C. ____________ __________ ____________ ____________

6. Score 7. Sig. Y or N?

Normal Operating Conditions

1.

2.

3.

Abnormal Operating Conditions

1.

2.

3.


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Appendix B #2

Sample #2 -- Process Flow Diagram Form for Documenting Inputs and Outputs and Related Aspects and Impacts

Beginning in the middle of the chart in Column No. 1, list the sequence of steps that comprise facility processes. For each of the process steps, identify the main raw material, water and energy inputs in Column No. 2 “input,” and product and waste outputs in Column No. 2 “output.” Remember that for every input, there should be a corresponding output. Account for all wastes and emissions. List normal and abnormal conditions and potential impacts including shut-down, upset or emergency conditions and previous incidents. Inputs and outputs are also aspects. List associated impacts for inputs and output in the appropriate Column No. 3. There may be multiple impacts per aspect. Impacts may be positive. An aspect is an element that can interact with the environment. An impact is any change to the environment wholly or partially resulting from the aspect. Note volumes, hazardous characteristics, frequency, etc. for each aspect in Columns No. 4. Note if there are any management controls in place relating to aspects in Columns No. 5. 5. Controls

4. Note volume, hazardous characteristics, frequency

3. Environmental impact

2. Input (aspect)

1. Process (activity, product, or service)

2. Output (aspect)

3. Environmental impact

4. Note volume, hazardous characteristics, frequency

5. Controls

ISO 14001:2004 Environmental Management SystemDesign Guidance and Timeline

Appendix C

Potential Aspect Categories and Associated Impacts

Aspect categories Potential impacts Negative impacts Air emission sources Air pollution Surface water contamination Human/animal/plant health degradation Wastewater & liquid waste sources Surface water contamination Groundwater contamination Soil contamination Human/animal/plant health degradation Solid waste sources (non-liquid) Land consumption (landfilling) Soil contamination Groundwater contamination Surface water contamination Human/animal/plant health degradation Hazardous & special waste sources Surface water contamination Groundwater contamination Soil Contamination Human/animal/plant health degradation Renewable and nonrenewable natural resource consumption

Depletion of water resources

Depletion of land resources Depletion of energy resources Appearance issues Local aesthetics degradation Noise sources Local aesthetics degradation Human/animal health degradation Odor sources Local aesthetics degradation Traffic issues Local aesthetics degradation Positive impacts Recycling / reuse / source reduction Conservation of natural resources Reduction of air, water and land impacts Land preservation / habitat creation Conservation of land resources, wildlife habitats,

preservation of cultural heritage Local aesthetics improvement

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Appendix C - continued

Potential Significant Scoring Criteria

Environmental Concerns Business Concerns Scale of impact Potential regulatory or legal exposure Severity of impact Concerns of interested parties Likelihood of impact Effect on public image Duration of impact Effect of change on other activities and processes Quantity of impact Difficulty of changing the impact Frequency of occurrence of the impact Cost of changing the impact

Examples of Significance Criteria and Rating Scheme

Category High (3) Medium (2) Low (1) Scale of impact National/global Regional Local Severity of impact Potentially life

threatening or life altering to humans, flora, or fauna

Danger of non-life threatening health effects to humans, flora, or fauna

Little danger to the health of humans, flora, or fauna

Likelihood of occurrence Almost certain to occur Somewhat likely to occur

Not likely to occur

Duration of impact Long term effects on the environment

Short term effects on the environment

Little effect on the environment

Frequency of occurrence of impact

Weekly to daily Monthly to weekly Less than monthly

Potential regulatory or legal exposure

Possible criminal action or significant fine

Notice of violation or fine

Issue not regulated or little possibility of violation

Concerns of interested parties

Frequent or high level of concern

Occasional concerns Little to no concern


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Appendix D Sample Objective and Target #1

Goal (Objective): Reduce surface water pollution (normalized reduction)

Target: Reduce annual total nitrogen discharged per pound produced 10 percent by 2006 from 2002 baseline

Performance indicator Year Value Units Normalization factor Baseline - 2002 0.025 Lbs. N per lbs of production 250,000

Target - 2006 0.0225 Lbs. N per lbs of production Sample Objective and Target #2

Goal (Objective): Reduce energy consumption (total reduction)

Target: Reduce electrical use 10 percent by 2006 from 2003 baseline

Performance indicator Year Value Units Normalization factor

Baseline - 2003 25,000,000 kWh NA Target - 2006 22,500,000 kWh


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Appendix E

Examples of External Communication by ESI Stewards

• Posted facility environmental policy and environmental performance data on Web site. • Given presentations to community leaders, neighbors, educational institutions and others. • Hosted an annual contractor meeting to discuss facility environmental goals and hear concerns. • Used facility resources to sponsor a community recycling center or accept recyclable materials into a

company program. • Adopted a portion of a community park or highway or given funds to support these. • Prepared and distributed annual environmental reports to community leaders, neighbors, educational

institutions and others. • Participated at environmental events or on groups at the local, state or national level. • Allowed local agencies site access to gain familiarity with emergency response systems and for

agency practice drills. • Participated in research studies regarding environmental practices. • Audited external communication during every internal audit cycle.


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Appendix F

Registrar Selection Doug Stimson, Waste Reduction Partners

The following questions may be helpful to consider when selecting a registrar. Consider interviewing a number of registrars to gain an understanding of the differences between them. When choosing a registrar, you are starting a relationship that will last many years. You must make careful decisions to lay the groundwork for a smooth and lasting relationship. While all of the questions are important, the most important factor to consider is how well a registrar can work with you. This includes how well they know your industry, experience with similar organizations and how well they communicate with you (and your employees during an audit). It is less expensive to use a local registrar that can drive rather than fly to your facility. However, do not select a registrar on cost alone. Registration is an ongoing journey and your “comfort level” of working with the registrar over time is most important. Initial Questions for the Registrar Representative:

What accreditations do you have? In which countries are you licensed? Do you use the same lead auditor/auditors each time? Where would the auditors of this project come from? How many auditors would you use on this project? Can we meet the auditors who would work on this project? If we have questions and call in, can we talk to our auditor or do we talk to a different representative? What relevant industry experience do you have? How many and which similar facilities have you registered? How many auditors do you have in our SIC code?

Technical Questions for the Registrar Representative:

How do you interpret the standard? Do we have access to your interpretation? How do you handle pre-assessment audits? Do you recommend them? Are they mandatory? Do you have a checklist we can use to assess our own system? What method do you use to do a full system audit? What is the frequency of surveillance audits? What is covered at each surveillance audit? Is there advance notice of surveillance audit? Do you do a full system audit every three years? How do you determine how much time to spend on a full system/surveillance audit? Describe how you determine major and minor nonconformances. In what area of the standard do you find the most nonconformances?


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Appendix F continued How do you handle a major nonconformance? How long do we have to respond? Will you return to audit that section? If so, will you look at any other areas? How do you handle a minor nonconformance? How long do we have to respond? What experience does each of the auditors who are assigned to us have? Request to review bios of lead and other auditors including education, experience, companies audited, references. What method do you follow when there is a need to change auditors? How do we contact the auditors?

Questions for the auditor:

Approachability How do you make yourself available to people in the plant that have questions during the audit? What do you do when someone is too nervous to answer your questions? How do you set boundaries so everyone's time is used effectively?

Composure Describe a situation where you had to convey a point to a hostile or unreceptive audience. How do you make difficult decisions? How do you handle the unexpected?

Conflict Management Describe a conflict you handled well, and one you didn't handle well. Describe a time when you had to deliver bad news, and the receiver didn't take it well.

Ethics and Values Have you ever had to represent a position you didn't completely agree with? Have you ever had to give feedback that was more negative than the requester was expecting? What did you do? How do you handle confidential information a requester knows you have, but you can't or won't disclose?

Organizing Have you worked with union and non-union facilities? What are the differences? How many major projects have you managed at the same time? How have you managed projects with team members from other offices/locations/practices? How do you keep organized during an assessment/audit?

Written Communications What type of written communications will we receive?

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