ISO 14001:2004 Environmental Management System Design Guidance and Timeline

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1 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

2 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, or for more information on module training classes. Page 2 of 35

3 Suggested Steps for EMS Design and Timeline EMS Elements Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 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 Page 3 of 35

4 Summary of EMS Team Meetings by Week Month Timeline for EMS Design Week Team Activities Meeting 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 Determine significance. Meet in 1 week Begin operational control and emergency response planning. Meet in 3 weeks Develop monitoring and measurement program. Meet in 3 weeks Set objectives and targets. Meet in 2 weeks Develop O&T management programs. Meet in 2 weeks Begin document control. Meet in 3 weeks Develop corrective and preventive action process. EMS coordinator develops training schedule and competence evaluation. Meet in 3 weeks Review training and competence process. EMS coordinator develops process for evaluation of legal and other requirements. Meet in 4 weeks 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. Page 4 of 35

5 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 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 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. Page 5 of 35

6 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 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 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, Two slides show presentations from facilities on deciding whether to integrate an EMS with a quality management system - Listing of EMS training and workshops - Back to Timeline Page 6 of 35

7 Notes: Page 7 of 35

8 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) Page 8 of 35

9 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 Back to Timeline Notes: Page 9 of 35

10 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, 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. Page 10 of 35

11 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 Discussion in ISO 14004:2004, Environmental aspects Back to Timeline Notes: Page 11 of 35

12 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. Page 12 of 35

13 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-byelement. - 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 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. Back to Timeline Notes: Page 13 of 35

14 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: Page 14 of 35

15 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 Page 15 of 35

16 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: Page 16 of 35

17 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 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. Page 17 of 35

18 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. Page 18 of 35

19 - 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: Page 19 of 35

20 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. Back to Timeline Notes: Page 20 of 35

21 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. Page 21 of 35

22 - 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. Back to Timeline Notes: Page 22 of 35

23 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: Page 23 of 35

24 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. Page 24 of 35

25 See examples of external communication by Stewards to meet ESI program criteria in Appendix E. Back to Timeline Notes: Page 25 of 35

26 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: Guidelines for quality and/or environmental management systems auditing 13&ICS2=20&ICS3=10 Back to Timeline Notes: Page 26 of 35

27 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 noncompliance Cause of noncompliance Date Environmental impact, if any Equipment manuals/ operational procedures work instructions Associated forms Calibration requirements Responsible party Location Page 27 of 35

28 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 Normal Operating Conditions 2. Element that can interact with the environment (aspect) (+) or (-) 4. Change to the environment resulting from aspect (impact) 5. Significance Criteria A. B. C. 6. Score 7. Sig. Y or N? 3. Abnormal Operating Conditions Page 28 of 35

29 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 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 characteris tics, frequency 5. Controls Page 29 of 35

30 Appendix C Potential Aspect Categories and Associated Impacts Aspect categories Air emission sources Wastewater & liquid waste sources Solid waste sources (non-liquid) Hazardous & special waste sources Renewable and nonrenewable natural resource consumption Appearance issues Noise sources Odor sources Traffic issues Recycling / reuse / source reduction Land preservation / habitat creation Potential impacts Negative impacts Air pollution Surface water contamination Human/animal/plant health degradation Surface water contamination Groundwater contamination Soil contamination Human/animal/plant health degradation Land consumption (landfilling) Soil contamination Groundwater contamination Surface water contamination Human/animal/plant health degradation Surface water contamination Groundwater contamination Soil Contamination Human/animal/plant health degradation Depletion of water resources Depletion of land resources Depletion of energy resources Local aesthetics degradation Local aesthetics degradation Human/animal health degradation Local aesthetics degradation Local aesthetics degradation Positive impacts Conservation of natural resources Reduction of air, water and land impacts Conservation of land resources, wildlife habitats, preservation of cultural heritage Local aesthetics improvement Page 30 of 33

31 Appendix C - continued Potential Significant Scoring Criteria Environmental Concerns Scale of impact Severity of impact Likelihood of impact Duration of impact Quantity of impact Frequency of occurrence of the impact Business Concerns Potential regulatory or legal exposure Concerns of interested parties Effect on public image Effect of change on other activities and processes Difficulty of changing 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, Danger of non-life threatening health effects to humans, flora, Little danger to the health of humans, flora, or fauna flora, or fauna or fauna Likelihood of occurrence Almost certain to occur Somewhat likely to Not likely to occur 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 Weekly to daily Monthly to weekly Less than monthly impact Potential regulatory or legal exposure Concerns of interested parties Possible criminal action or significant fine Frequent or high level of concern Notice of violation or fine Occasional concerns Issue not regulated or little possibility of violation Little to no concern Page 31 of 35

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