Student Textbook ISO 14001:2004 Implementation Guide · calibrations performed are in conformance...

ISO 14001:2004 Implementation Training

© 2008 J.P. Russell & Associates and Total Logical Concepts, Inc.

Student Textbook

ISO 14001:2004 Implementation Guide (Based on a certified lead auditor training class)

By: Total Logical Concepts, Inc. and Quality WBT Center for Education

Note: The student textbook contains the text content of the class without interactive exercises, activities, glossary links, images, examples, key points, tips, tests, handouts or summaries. The student textbook can be used for off-line refresher and future reference after the class. The student textbook should not be used in place of the web-based training program.



Table of Contents LESSON A01: TERMINOLOGY AND DEFINITIONS ................................................................................... 3

LESSON B02: BACKGROUND, HISTORY AND RATIONALE OF ENVIRONMENTAL MANAGEMENT7

LESSON D04: ISO 14001-2004 CYCLE AND RELATIONSHIPS ............................................................. 21

LESSON D05: SCOPE AND DEFINITIONS ................................................................................................ 26

LESSON D06: GENERAL SYSTEM REQUIREMENTS/ ENVIRONMENTAL POLICY .......................... 28

LESSON D07: ENVIRONMENTAL ASPECTS / LEGAL AND OTHER REQUIREMENTS / OBJECTIVES, TARGETS AND PROGRAMS............................................................................................. 32

LESSON D08: RESOURCES, ROLES, RESPONSIBILITY AND AUTHORITY/COMPETENCE, TRAINING AND AWARENESS ..................................................................................................................... 40

LESSON D09: COMMUNICATION/DOCUMENTATION/ CONTROL OF DOCUMENTS ...................... 46

LESSON D10: OPERATIONAL CONTROL/EMERGENCY PREPAREDNESS AND RESPONSE....... 51

LESSON D11: MONITORING AND MEASUREMENT / EVALUATION OF COMPLIANCE .................. 56

LESSON D12: CORRECTIVE AND PREVENTIVE ACTION/CONTROL OF RECORDS ...................... 61

LESSON D13: INTERNAL AUDIT / MANAGEMENT REVIEW ................................................................. 66



Lesson A01: Terminology and Definitions Objective of Part A: To familiarize students with the terms that is associated with:

• the proper administration of the environmental management system

Discussion:

The ANSI / ISO /ASQ 14001-2004 American National Standard defines selected terms and provides background information about environmental fundamentals. When dictionary definitions are not sufficient to support the environmental management standards, definitions are provided in ISO 14001-2004 clause 3.

Note: Pull out your copy of 14001 or select the on-line 14001 access provided as part of this class. We have paid an on-line access license fee to ISO/ASQ for your convenience, but if you want your own personal copy for this class, you will need to borrow a copy from a friend or purchase one individually from ASQ. In some cases, the ISO/ASQ fee for a standard is more than the class enrollment.

Take out the ISO 14001 Standard now (or view on-line) and look through it

1. Turn to the table of contents and see how the standard is organized.

2. Turn to Clause 3, Terms and definitions and briefly review the definitions that apply to this standard. For those of you who are familiar with ISO 9000 notice those definitions that are "adapted" from that standard.

You will need to reference the proper definition of some terms from time to time to fully understand the environmental management system requirements and their intent. You will find that your knowledge of the definitions will be very useful in implementing an ISO 14001 environmental management system.

ISO 14001 Terms and Definitions

We do not have the time to discuss every word definition, so we have picked some that we think are especially important or have some aspect that you need to be aware of. The organization is the company, corporation, firm, enterprise, authority or institution that implements an environmental management system (EMS) as a systematic approach to dealing with the environmental aspects and resulting impacts within its scope. The environment is the surroundings in which an organization operates. This includes:



• air • water • land • flora • fauna • humans

...and their intervention The scope defines the boundaries of the organization to which your environmental management system will apply and is determined by top management. This is especially important if you have multiple locations and/or processes. An environmental management system is a tool that helps the organization control the environmental impact of its products and services, helps the organization develop its environmental policy and focuses on continual improvement to environmental performance. Two of the most important definitions that you will need to understand and apply are environmental aspect and environmental impact. A significant environmental aspect is an aspect that has or potentially can have a significant impact on the environment. A change to the environment (impact) takes place when something is released into the air, into the water, when something contaminates the soil or when a resource is consumed. The change may be good or bad. Although it is common practice to use the terms conformance and compliance interchangeably, in the world of ISO 14001 there is a very distinct difference. Conformance is used when referencing the ISO 14001 standard, such as” the documented environmental policy meets the requirements of clause 4.2, “or “the calibrations performed are in conformance with the documented schedule. Compliance is used when referencing “compliance” to federal, state, and local rules and regulations and may carry legal implications.

Regarding nonconformance A nonconformance is the “non-fulfillment of a requirement” and generally requires corrective action. Once a nonconformance has been identified we may need to take immediate action to correct the situation in order to mitigate its environmental impact. For example, if an operator is not following the procedure for handling chemicals we must correct this issue and ensure that he/she handles the chemicals properly. After correcting the immediate problem, we must determine what prevented the operator from handling the chemicals properly in the first place. Was the procedure documented? Did he/she have access to the procedure? Was the procedure unclear?



We take corrective action to determine the root cause of the nonconformance and implement the actions necessary to prevent it from happening again or from recurring. If this situation had never happened before and we developed and documented a procedure to prevent this type of thing from ever happening or occurring, we would have implemented preventive action. Regarding prevention of pollution ISO 14001 requires organizations to make a commitment to the prevention of pollution as part of their environmental policy. This includes the use of:

• Processes • Practices • Techniques • Materials • Products • Services • Energy

Consider: source reduction or elimination, process, product or service changes, efficient use of resources, material and energy substitution, reuse, recovery, recycling, reclamation and treatment...when preventing pollution as part of your organization’s environmental objectives and targets.

Regarding audits As standards evolve, such as the auditing and environmental standards, so does our need to understand the terminology used by the auditors and audit experts. The term environmental audit is not in the terms and definitions, but has been replaced with the generic term, audit. There is little difference between the "quality audit," “environmental audit,” and "audit" definition.

The audit definition simply requires that audits determine the extent to which the audit criteria are fulfilled. The audit criteria may be determined on an audit-by-audit basis.

Regarding documents

A document is information (meaningful data) and its supporting medium (paper, electronic, film, and so on). A document can be a record, specification, procedure, drawing, report or a standard. A set or collection of records or specifications can be called ‘documentation. A procedure, which may or may not be documented, specifies a way to carry out an activity. A record is a type of document that states results or evidence of activities performed (determines what was done).



Abbreviations

While learning about or implementing an ISO 14001 environmental management system you will run into several abbreviations or acronyms that you may need to be aware of. There are those that are commonly recognized

• ANSI American National Standards Institute • EPA U.S. Environmental Protection Agency • FDA Food and Drug Administration • ISO International Organization for Standardization (not an abbreviation) • OSHA U.S. Occupational Safety and Health Administration (or Act)

And those that you may recognize based on your industry • FIFRA U.S. Federal Insecticide, Fungicide and Rodenticide Act • NPDES National Pollution Discharge Elimination System • RCRA Resource Conservation and Recovery Act

In the next lesson we will discuss the basis and evolution of environmental management. Knowing the history will help you understand how the standard has evolved to what it is today.



Lesson B02: Background, History and Rationale of Environmental Management This lesson is long and discusses the history of environmental management. Knowing the history of environmental management and how we got to where we are today will help you to:

1. be in a better position to implement an ISO 14001:2004 environmental management system

2. put environmental management into perspective 3. explain the benefits of adopting an environmental management system (EMS) to

others When you understand history, you will understand why we do what we do and how we got to where we are with regard to our environmental practices. History is only a small but a valuable part of this class. Traditionally when organizations considered implementing “Environmental Management Systems” they saw these systems as a way to avoid potential problems and negative consequences. Today enlightened organizations see an “Environmental Management System” as a way to conserve, avoid risks and save money and be environmentally conscious at the same time.

Philosophy and Background of Environmental Management

Environmental Management is not about eliminating pollution. The real issue is improving and sustaining our standard of living.

The ultimate goal is to integrate EMS activities into everyday business and operations.

The increase in the number of EMS standards on national, industry and local levels has encouraged organizations to adopt a formal approach to managing their environmental impacts.

Citizen Law suits are becoming more common as the public increasingly expects federal, state and local government to be actively involved in enforcing current laws and achieving results!

Environmental liability is beginning to flow backward to those not traditionally held accountable. Organizations are now even listening to the public and their demands for more responsible environmental management!

Environmental Regulations



EPA: Established in 1970 to protect human health and the environment Legal Requirements include: Federal-State-Local Laws, Regulations, Permits, Contracts, Consent orders, Memorandums of agreement

The Evolution of Environmental Legislation and Other Requirements

Environmental issues are not new. Back in the 1700s if you were traveling by horse, buckboard, carriage or stage coach and one of your horses died, you left it on the side of the road and moved on. Things such as water and soil contamination had not yet been identified as environmental concerns. People got sick but they didn’t know why.

Later, as people began to realize the ramifications of dumping garbage into the water, a new law was enacted.

1899 Law prohibiting dumping of refuse into navigable water In 1962, Rachel Carson, an avid bird watcher was afraid that there would be fewer birds singing each spring unless pesticide poisoning was stopped. As people read her book, they grew more concerned about dying from their pesticide laden salads than the lack of singing birds.

1962 Silent Spring by Rachel Carson warns of environmental damage by pesticides,

environmental movement publicized From 1962 to 1970 overpopulation and industrialization left us trapped in an environment that was deteriorating. The damage threatened the existence of mankind itself. By 1969 the environmental movement had taken a strong foothold thanks in part to television programs and symposiums.

In December of 1969 President Nixon appointed a White House committee to decide whether or not there should be a separate federal environmental agency. At the same time Congress sent a bill to the president known as the National Environmental Policy Act (NEPA).

1970 National Environmental Policy Act. US EPA is established along with the Clean Air Act.

The 1899 law was extended to include industrial wastewater. In 1980 looking back in history, Senator Gaylord Nelson (D-Wisconsin) called NEPA “the most important piece of environmental legislation in our history.” Growing public awareness and concern for controlling water pollution led to the enactment of the Federal Water Pollution Control Act Amendments of 1972. In 1977, this law became commonly known as the Clean Water Act.

1972 Water Pollution Control Act



The Act established the basic structure for regulating discharges of pollutants into the waters of the United States. It made it unlawful for any person to discharge any pollutant from a point source into navigable waters, unless a permit was obtained under its provisions. In 1966 Congress passed the Endangered Species Preservation Act to protect the whooping crane. The Act allowed the Secretary of the Interior to compile a list of endangered fish and wildlife and allowed Fish and Wildlife Services to spend up to $15 million per year to purchase listed species habitat. The Pentagon protested the listing of sperm whales because they used sperm-whale oil in submarines but the Secretary added them anyway. Because of this it became clear that a new, stronger law was required.

In 1973 Congress passed a completely rewritten Endangered Species Act.

1973 Endangered Species Act

The new law distinguished threatened from endangered species, allowed listing of plants and invertebrates, authorized unlimited funds for species protection, and made it illegal to kill, harm, or otherwise "take" a listed species. In effect, the law made endangered species protection the highest priority of government. By 2002, the US government had enacted a number of pieces of legislation including the Safe Drinking Water Act (1974), the Toxic Substances Control Act (TSCA) and the Resource Conservation and Recovery Act (RCRA) (1976), and The Comprehensive Environmental Responsibility Compensation and Liability Act (CERCLA, aka Superfund) (1980).

Several worldwide events occurred that continued to enforce the need for environmental management. In 1978 the Love Canal toxic waste dump was nationally exposed, where 82 different compounds, 11 of them suspected carcinogens, had been percolating upward through the soil, leaching their contents into the backyards and basements of 100 homes and a public school. 221 families lost their homes.

In 1984 the world was horrified by the Bhopal, India disaster where on the night of Dec. 2nd and 3rd, 1984, a Union Carbide plant in Bhopal, India, began leaking 27 tons of the deadly gas methyl isocyanate. Half a million people were exposed to the gas and 20,000 have died to date as a result of their exposure. More than 120,000 people still suffer from ailments caused by the accident and the subsequent pollution at the plant site.

In 1995 The US EPA Office of Wastewater Management encouraged the use of ISO 14001 or an alternative EMS to facilitate NPDES permitting.

The Energy Policy Act of 2005, which the President signed into law, authorized $5 billion over five years in tax incentives to encourage investments in energy efficiency



and alternative renewable energy sources. The new energy law provided new performance-based tax credits of up to $3,400 for the most highly fuel-efficient vehicles such as hybrids and clean diesel. It also established 15 new appliance efficiency mandates and a 7.5 billion gallon renewable fuel requirement by 2012.

Trends

People all over the world, including emerging industrial nations are becoming increasingly sensitive to environmental violations. Since documents such as permits, reports, violations, fines and enforcement activities have become so easily accessible, public awareness is at its highest level in years.

With the advent of the internet, people living anywhere can find all of the information they want or need within minutes.

For example: Vitasoy Inc. charged with environmental violations, ordered to pay $12k� Article Launched: 05/25/2007 08:29:38 AM EDT �AYER -- Vitasoy Inc., operator of a soybean processing plant at 1 New England Way, has been charged with paying a $12,000 penalty to the commonwealth of Massachusetts for violating air pollution control, hazardous waste management and industrial wastewater regulations. Consumers are becoming increasingly environmentally conscious. We are looking for and purchasing environmentally friendly products and practicing recycling. Large companies have had environmental staff and environmental management systems for years.

But now, the reasons that have driven large organizations are becoming increasingly valid for smaller organizations or SMBs (small and medium sized businesses).

Benefits for Business

Any business will do what it has to do to avoid pollution and comply with environmental regulations that could save the company a large fine, but that is more of a reactive approach than a proactive approach. In this ever growing environmentally conscious world, that approach no longer makes the grade! Implementing an ISO 14001:2004 environmental management system forces you to take a hard look at all areas where your organization may be causing an environmental impact. In doing so a well constructed EMS can result in the following benefits including a direct cost savings which is money that goes directly to the bottom line!



Some Benefits for Business Materials waste reduction Recycling and recovery Reduced packaging Material substitution with environmentally compatible materials Reduce cost of disposal Consumption of energy and materials (See Lesson for additional benefits)

Regulatory Trends Regulatory requirements continue to increase with widespread public support. A properly implemented and maintained environmental management system can guide you in implementing processes that aid with compliance. A properly implemented EMS may:

• Streamline permit applications • Reduce monitoring • Result in fewer and/or shorter audits and Lower fines!

Kmart will pay a $102,422 fine to settle self-disclosed violations of federal environmental regulations discovered at 17 distribution centers in 13 states. The company reported violations of clean water, hazardous waste, and emergency planning and preparedness regulations to the U.S. Environmental Protection Agency. If EPA had discovered Kmart’s violations through an inspection, the company would have faced a fine of more than $1.6 million.

ISO 14001 and the U.S. Government

Because the 1990s found us with such issues as the environmental disaster created during the Persian gulf war with thousands of burning oil wells, the introduction of MTBE which fought air pollution but was found to carry a major side effect of water pollution, and a Gallup poll that found 76 percent of Americans call themselves “environmentalists,” the government decided once again that it was time to step up and introduce major legislation. In April 2000 the White House issued Executive Order 13148, Greening the Government Through Leadership in Environmental Management. The order applied to all appropriate federal facilities that had operations which interacted with the environment and included a number of environmentally-related requirements. The most significant requirement was that all appropriate federal facilities must implement an Environmental Management System (EMS) by December 31, 2005. This order affected federal laboratories, testing facilities, maintenance facilities, hospitals and so forth



across all federal departments and agencies. The order was designed to enhance performance in environmental management, environmental compliance and public right-to-know. It sets goals for federal facilities on pollution prevention and employing environmental management systems. The World Trade Organization and Section 12 of the National Technology Transfer Act, obligates the U.S. government to give preferential consideration to international voluntary standards in developing regulations.

ISO 14000 is playing a role in the U.S. Government’s procurement policies related to environmentally-preferable products. The Department of Energy and several other government agencies have required some major contractors to establish EMSs and have themselves implemented ISO 14001:2004.

The Strategic Petroleum Reserve in Louisiana and Texas and 6 other DOE facilities have implemented ISO 14001:2004.

ISO 14001 and the U.S. EPA Recently the EPA reissued its Position Statement on Environmental Management Systems (EMS). The revised position statement reaffirms the Agency’s long-held opinion that implementing an EMS will enable businesses, agencies and other institutions to improve their environmental performance and business competitiveness. The EPA's position includes several key points:

• EPA policies reduce the enforcement response for organizations performing environmental auditing and offers incentives for voluntary disclosure.

• In general, the EPA will follow the U.S. Government’s trend to take into account a company’s compliance assurance programs in its response to incidents.

• The EPA is looking for ways to move from command-and-control posture to preventive approaches such as ISO 14000 and anticipates more reliance by companies on independent auditing and self-declaration as the primary way to achieve prevention.

• Improved regulatory efficiency is an expected benefit to the EPA and regulatory agencies in other countries.

• Governments can ease the oversight of better performers and direct their attention to serious offenders.

Registration Audit Drives Environmental Improvement

The combination of requirement standards and third-party audits (registration / certification audits) form the basis for the conformity assessment process. Registration / Certification audits verify conformity to requirements. Beside the obvious benefits of



auditing, other benefits are derived from the audit process. On the next screen are some advantages of being registered by a third-party organization.

While EMS’s provide their own set of benefits, organizations should be aware of the additional benefits that may be provided by ISO 14001:2004 registration audits:

• Provides discipline • Provides feedback to management and demands management attention • Causes continual improvement • Registration as a goal

EMS Cost Considerations: When considering implementation of an ISO 14001:2000 environmental management system consider:

• Prevention costs for EMS development (including ISO 14001:2004 implementation and certification fees)

• Civil and criminal penalties associated with regulatory issues • Lending institutions are asking for assurance that property transactions do not

include environmental problems • Currently, U.S. companies spend about 2% of their sales revenue on

environmental management • It is estimated that 20% of corporate capital investments are targeted for

environmental projects • Costs are especially critical to smaller-sized companies, which comprise over

75% of the world’s industry A poorly implemented and/or maintained environmental management system has the potential to undo all of the hard work that has been done by the many people involved. There are also more serious risks. Weak or poor implementation can result in:

• High costs • Increased exposure • Increased stakeholder expectation / dissatisfaction • Internal effort / time • No payback • Increased bureaucracy, paperwork

Resources A wealth of information is available on the internet, from the federal government or your state EPA.



To begin your search you may want to consider the following; The National Service Center for Environmental Publications (NSCEP) Web Site: www.epa.gov/ncepihom/ Phone: 513-569-7751 Fax: 513-569-7186 Mail address: US EPA � National Service Center for Environ. Publications� 26 West Martin Luther King Dr� Cincinnati, OH 45268 United States Environmental Protection Agency: www.epa.gov List of Clearinghouses: www.epa.gov/epahome/clearing.htm Educational Resources: www.epa.gov/epahome/educational.htm Natural Environment Research Council: http://www.nerc.ac.uk/ In the next lesson we are ready to start learning about the ISO 14001 family of standards and how they are to be used.



Lesson C03: Introduction to ISO 14001:2000 This lesson is long, discusses standard design, uses and the environmental management principles. ISO 14001:2004 is part of a family of documents that work together to provide support for environmental management systems. All 14000 numbered documents relate to environmental management systems. 19011:2002 contains the guidelines for environmental auditing and there are several documents titled “Guide.” This lesson is about this family of documents. This material is presented so that you will:

1. learn about the environmental management system’s family of documents 2. know where to get additional guidance 3. be able to direct others who need help

The technical committee, TC 207, was formed in 1993. The ISO committees have a basic methodology for creating consensus standards. After a standard is proposed, there is a series of reviews by member nations until the final consensus standard is ready for publication. The review process can take several years. There is a vote at each step to determine if the standard needs more work at that stage, or if it can be moved to the next stage or the work on the standard is discontinued. The ISO Technical Committees (TCs) create the standards with input from sector-specific interests. When the creation process is complete, member nations vote to accept the standards. International Standards exist to serve many diverse industry needs. The goal of TC 207 was to create a generic standard for Environmental Management Systems.

• In March of 1992 the draft version of British Standard 7750 was published. It became the model used by ISO for 14001.

• In 1993 ISO assigned TC 207 to create the ISO 14000 environmental management series.

• In January 1994 BS 7750 was revised in order to make it compatible with EMAS and ISO 14001

• The first version of the ISO 14000 series of documents was published in 1996 with the second and current revision published in 2004.

• The next revision is scheduled for 2009 or later. ISO 14001:2004 does include a certain amount of guidance within the same document in the form of an appendix. But just like ISO 9001 an additional guidance document can be found in the form of ISO 14004:2004 Environmental management systems: General guidelines on principles, systems and supporting techniques.



If you are not familiar with the principles of implementing an ISO 14001 management system you may find this document very helpful. ISO 14001:2004 does include a certain amount of guidance within the same document in the form of an appendix. But just like ISO 9001 an additional guidance document can be found in the form of ISO 14004:2004 Environmental management systems: General guidelines on principles, systems and supporting techniques.

The ISO 14000 model

ISO 14001 is the starting point for organizations that may want to use other environmental management tools developed by ISO/TC 207.

ISO 14001 and 14004 are based on the Plan, Do, Check, Act Continual Improvement Cycle. To aid in the “Planning” part of the cycle, organizations can use the ISO 14040 Life Cycle assessment series. This series covers the principles and framework for life cycle assessment of products as well as helps with the definition and scope of a life cycle assessment and the life cycle impact assessment. Another helpful “planning” document is ISO 14062 which contains guidelines for integrating environmental aspects into product development to design in ”sustainability.”

For assistance with the “Do” part of implementing ISO 14001, check out the ISO 14020 series and the ISO 14063 series. ISO 14020 will help you understand the guiding principles that are behind the use of environmental labels and declarations; while 14063 will give you help and examples of how to implement an effective communication process in order to have a functioning, efficient environmental management system.

For monitoring and measuring performance as part of the “Check” portion of the cycle use the ISO 14030 series for guidance on how to evaluate environmental performance.

ISO 19011 can give you the fundamentals of auditing, how to manage the audit program, how to conduct audits and qualifications for auditors. This will help you monitor the effectiveness of your environmental management system.

Go to Course Tools/ Guide Documents for model as a pdf file.

The Future

Because environmental issues are constantly changing, environmental management systems need to change as well. The ISO 14000 series of documents will continue to improve and change over time.



One of the goals is to continue to seek compatibility between Quality, Environmental and other potential future standards. ISO 14010, 14011, 14012 and 10011 have all been replaced by ISO 19011 Guidelines for quality and/or environmental management systems auditing. Future revisions and additions of the ISO 14000 series of standards and associated documents will play a role in addressing issues such as

• Understanding and concern from the public and environmental professionals regarding sustainable development.

• Increased emphasis on global warning.

Environmental auditors and practitioners will need to keep themselves current with environmental issues and the resulting changes over time.

Implementation There are six main steps that you can follow to implement an ISO 14001:2004 Environmental management system.

Establish Environmental Management Program

Establish Environmental Policy

Identify Environmental Aspects

Monitor and Measure

Management Review

Determine Objectives and Targets Legal and Other Requirements



While implementing an ISO 14001 EMS it is important to do the 6 main steps in the proper order: 1st: Establish Environmental Policy Senior managers must commit to environmental improvement and establish an organizational policy. The policy is the foundation of the EMS and is shared with employees and the public. 2nd Identify Environmental Aspects An organization first identifies the environmental aspects of its operation. Environmental aspects are things such as pollutants or hazardous waste that can or may potentially have a negative or positive impact on people or the environment. An organization then determines which aspects are significant by using criteria most important to the organization. 3rd Determine Objectives and Targets The organization sets objectives and targets based on its significant environmental aspects. An objective is the environmental goal, a target is the measurable requirement. Remember to include legal and other requirements when developing your objectives and targets. 4th Establish Environmental Management Program The final part of the planning stage is devising an action plan for meeting the targets, incorporating strong operational controls and environmental responsibilities into existing job descriptions and work instructions. Plans include roles and responsibilities, identifying training needs, establishing a schedule, describing procedures to measure and document results and clearly defining the steps needed to meet the defined targets. 5th Monitor and Measure An organization monitors and documents its operations to evaluate whether targets are being met. If targets are not being met, the organization takes corrective action. 6th Management Review Senior management reviews the results of the evaluation to see if the EMS is working. Management determines whether the original environmental policy is consistent with organizational values. As appropriate, the plan is revised to enhance the effectiveness of the EMS. The review stage creates a loop of continuous improvement.

Environmental Aspects and Impacts A good understanding of Aspects and Impacts is important in implementing an ISO 14001 environmental management system.



An environmental aspect is: something that your organization does (activity) as part of your business practices that interacts or may potentially interact with the environment either positively or negatively An environmental impact is: the change that takes place in the environment, good or bad as a result of the aspect A change to the environment (impact) takes place when something is released into the air, into the water, when something contaminates the soil or when a resource is consumed. The change may be good or bad.

Determining Significance

Evaluate your environmental impacts to determine significance.

The California Environmental Quality Act defines a significant impact on the environment as “a substantial, or potentially substantial, adverse change in any of the physical conditions within the area affected by the project, including land, air, water, minerals, flora, fauna, ambient noise, and objects of historic or aesthetic significance.”

A significant aspect is an aspect that has or can have a significant impact on the environment.

Determining Significance

What makes an impact significant? • The scale of the impact • The probability of it occurring • How often the impact occurs and the duration

From a business perspective, what else could make an impact significant?

• Stakeholder concerns • Cost of changing the impact • Difficultly in changing the impact • Local, state and federal regulations • Effect on the public image of the organization • Effect of the change on other activities or processes

The reason we identify significant aspects and impacts is because we cannot possibly focus improvement efforts on every aspect and impact our organization generates. By assigning significance we are able to determine which ones we will focus our improvement efforts on. Generally, aspects that come through the significance ranking process as high, are probably already receiving a great deal of emphasis within your organization. For



example, if you deal with hazardous materials you probably have a hazmat training course available that is given to all employees working in areas where these chemicals are stored, used, transported or disposed of. More than likely you already have very clear instructions as to how these materials should be handled since failure to properly follow procedure could result in disastrous consequences to flora, fauna and humans. There is no standardized method for identifying significance and no standardized criteria categories or evaluation schemes. ISO 14001 allows you, the organization, the flexibility to develop a significance determination process where you decide what is most important to you.

By assigning significance to your impacts you can concentrate your prevention, compliance and continual improvement efforts on those impacts that will be the most value added. There are several different categories that you can use to rank your impacts.

The important thing is that your organization addresses its concerns. The next lesson starts off with the actual clauses of the standard. It is the beginning of learning about the specific requirements and their application.



Lesson D04: ISO 14001-2004 Cycle and Relationships The next series of lessons (grouped as part D) and activities are very important for successful completion of this class. The material in the following lessons is paraphrased for instructional purposes. Only the actual language of the standard is the language that is to be used for implementation purposes and for a conformance audit. The ANSI/ISO/ASQ 14001-2004 Environmental management systems – Requirements with guidance for use is the source document and should be referenced regarding the need for interpretation of requirements. During the class you may want to follow along the discussion with your copy of the standard or use the on-line version of ANSI/ISO/ASQ 14001-2004 provided as part of this class. Open your standard and turn to the introduction to start this lesson.

Introduction This is the big picture clause. It does not contain any baseline auditable requirements but there is valuable information that will affect the environmental management system (EMS). Lesson Topics

• Linkage between clauses and appendix • Overview of the EMS cycle • Linkage to ISO 14004 and other management system standards

Joining standards

All types of organizations are becoming more concerned with controlling their environmental aspects. As this concern increases so does more stringent environmental legislation and economic policies.

Environmental standards join with other standards such as ISO 9001 the quality management system standard and OHSAS 18001, the occupational health and safety standard, to offer organizations a way to implement an effective environmental management system to aid them in achieving their environmental goals as well as their other goals.

Linkage between clauses and the appendix A

ISO 14001 specifies the requirements for implementing an environmental management system that allows an organization to develop policies and objectives taking into account its legal requirements and its significant environmental aspects. As additional guidance to help with understanding some of the requirements, Appendix A has been added to the requirements standard. For ease of use the sub-clause numbers in the standard and in the appendix are related. For example, 4.3.3 and A.3.3 both deal with objectives, targets and programs.



Certification is to ISO 14001

It is important to remember that ISO14001-2004 is the only document in the group of environmental documents developed by TC207 that contains requirements that are “auditable". Although the other documentation contains helpful guidance about specific areas of environmental management, if your organization desires certification to ISO 14001, this is the standard on which you must base your EMS

Plan-Do-Check-Act Next, using the PDCA model you will be given a brief overview of the clauses of the standard and how they relate to each other and to the continual improvement cycle.

4.2 Environmental Policy – Plan

One of the first things that top management must do is make a commitment to the environmental management system. The environmental policy is where this is documented. It contains the environmental vision of the organization on which the EMS is predicated. It sets the stage for the development of environmental objectives and targets. It is here where top management makes the commitment to comply with legal and other requirements to which the organization subscribes, the commitment to prevent pollution and the commitment to continually improve.

4.3.1 Environmental aspects – Plan

After the development of the policy, this clause is the next step in planning for most organizations. In order for an organization to implement an effective EMS they must understand what activities, products and services they have which may have elements that interact or may potentially interact with the environment. A procedure must be developed and maintained that describes how aspects and the corresponding impacts are identified.

4.3.3 Objectives, targets and programs – Plan

Once significant environmental aspects and their corresponding impacts have been identified, it is time in the planning step for the organization to set some goals and targets for environmental improvement. These goals and targets should fulfill the commitment made in the environmental policy and plans should be developed on how these goals and targets will be achieved. By doing this, the organization gives itself a systematic process for continually improving.



Consideration should be given to the views of interested parties such as shareholders, employees and neighbors.

4.3.2 Legal and other requirements – Plan

As part of planning organizations must develop a process for identifying the legal requirements with which they must comply. They must also include any “other” requirements they comply with, including voluntary and local programs. The reason the organization does this is so it can be aware of the requirements and determine how they apply to the organization. Once defined, this information must be communicated to employees and others who may do work on behalf of the organization, such as contractors. These requirements should be considered when developing objectives and targets.

4.4 Implementation and Operation –Do

This is the beginning of the “Do” part of the improvement cycle. This is where the organization begins to construct its EMS based on the planning elements it has established. Responsibilities and authorities are determined and defined, training of personnel occurs, and methods of communicating are established. Required documentation is identified and methods for its control are developed and implemented. There will be some tasks or job functions that have the potential to cause an impact on the environment. For these jobs, operational controls must be put into place to ensure that employees are aware of the environmental impacts of their jobs. Procedures for day-to-day tasks are documented and implemented. Procedures must be developed to identify potential emergencies and the response to them in order to mitigate environmental impacts that may occur. These procedures must be tested, if possible, and adjustments made, if required.

4.5 Checking –Check

As you may have guessed from the title of this clause, this is the part of the standard where we do the “Check” part of the Plan Do Check Act cycle. This clause has a few requirements in it and for good reason. How can you measure improvement if you are not monitoring your processes and recording the results? As an organization, you are required not only to measure progress towards objectives and targets but to also measure “key characteristics” that can have significant environmental impacts. In order to make these measurements, you must have measuring equipment and a program for calibrating it to ensure it remains accurate. This is also the section where organizations must evaluate their own compliance with legal and other requirements. This does not necessarily have to be an audit and it does not have to be done by a third party, however there must be a procedure in place for



getting it done. Records must be kept of these evaluations. It is during this checking phase of the continual improvement cycle where we find the process for identifying nonconformances and taking actions to mitigate their environmental impacts. The nonconformances must be investigated and a determination must be made as to the appropriate corrective action or preventive action to be taken. Records of these actions must be maintained. Because we are required to keep records to show that we conform to the requirements of our EMS and the standard, we must have a way to control them. We must have procedures that indicate how we identify, store, protect, retrieve, retain and dispose of records.

4.6 Management review – Act

Management review makes up the “Act” portion of the continual improvement cycle. Management is required to review the health of the EMS to ensure it still meets the needs of the organization and to make recommendations for improvements. Based on the outcome of the management review the cycle begins again with changes to the Plan followed by Do Check and Act all over again. This is why it is called continual improvement.

Relationship to ISO 14004 ISO 14001 contains requirements that can be objectively audited. For those organizations that would like assistance in implementing or improving an EMS with a resulting improvement in their environmental performance, ISO14001-2004 has been developed. ISO 14004 is consistent with the concept of sustainable development and contains examples, descriptions and options to aid in the development of an EMS and relate to the overall management of an organization. While the guidelines in this standard are consistent with the 14001 model they are NOT intended to provide interpretations on the requirements. For ease of use, the clauses of 14004 have the same numbering system as 14001, however 14004 has extra sub-clauses where additional guidance would be useful.

Compatibility with other management systems The 14001 standard has been aligned with other management system standards such as ISO 9001(quality management system), or OHSAS 18001 (occupational health and safety) for the benefit of organizations using all of these standards. ISO 14001 does not include requirements specific to the other management systems, however it allows an organization to align or integrate its system with related management system requirements.



Top management commitments The only absolute requirements in this standard are the commitments top management makes in the environmental policy. These are the commitments to:

• Continual improvement • Prevention of pollution • Comply with applicable legal requirements • Comply with other requirements

Because of this, two organizations that have similar operations may have completely different environmental performance and still comply with the same standard. Remember compliance with the standard does not in and of itself guarantee optimal environmental performance. The standard encourages the organization to achieve its environmental objectives by using the best technology available where economically viable. In Lesson D05, we will look at the actual standard scope and how it applies to various organizations.



Lesson D05: Scope and Definitions The topics to be discussed in this lesson are:

• Scope of the environmental standard • Definition of terms used in the environmental standard

The scope and tailoring of the standard for an organization’s EMS are important to both auditors and users of the standard. For effective implementation users need to:

1. determine those significant environmental aspects which their organization can control and influence

2. know the legal and other requirements to which the organization subscribes Auditors need to be able to:

1. develop a scope using the rules for development 2. verify proper determination by users

Scope Clause 1

Principle Concept: • The standard applies only to those environmental aspects that an organization

has control over. • The standard can be used by organizations desiring to improve their

environmental performance Discussion: This clause explains the scope of the standard in that it is a generic standard and may be used by all sizes and types of organizations to implement environmental policies and objectives. The standard should be implemented when an organization wants to:

• Establish, implement and improve an environment management system • Ensure that it continues to conform with its own environmental policy • Demonstrate conformance to an International Standard

Application

It is important to note that the requirements of the standard can be used in any EMS. The application depends on the organization’s activities, product, services, where it is located and the environment in which it conducts business. The standard does NOT prescribe any specific performance criteria. It was developed as a tool for organizations



to use to improve their own environmental performance. You must decide how the standard applies to your organization.

Normative References – Clause 2 Discussion: There are no normative references.

Terms and Definitions – Clause 3

Discussion: Important terms were discussed in Lesson A01 with corresponding glossary links. ISO 14001 Clause 3, references specific environmental terms. Clause 4 marks the start of the ISO 14001 EMS requirements. If you are not familiar with standard writing styles you may want to take a couple of minutes to review the information in the handout (Finding Requirements in Standards). Most standards conform to a style that makes them more professional and improves their utility to the users (readers). The next lesson will show the overall system view and set the stage for the clause-by-clause discussion.



Lesson D06: General System Requirements/ Environmental Policy Clause 4 marks the start of the ISO 14001 QMS auditable requirements. Objectives: The student will be able to:

• Understand how to develop and document an EMS policy • Write scope statements that are clear, concise, and auditable • Determine what documentation is required for this standard

4. Environmental Management System Requirements 4.1 General Requirements 4.2 Environmental Policy Principle Concepts:

• Establish a system to meet requirements • Document and define the scope of the system • Top management must ensure there is an environmental policy

4.1 General Requirements

Discussion: The key points are:

• You must establish a system, maintain it and improve it • It must be compliant with the requirements of the standard • You must determine how you will fulfill these requirements.

Management review (Clause 4.6) can be used to attest to the maintenance and on-going improvement of the system.

EMS Scope The scope of the environmental management system defines the “environmental boundaries” to which the EMS applies. Once the scope has been defined all activities, products and services within that scope should be included in the EMS. ISO 14001 is very flexible when it comes to defining the scope for an organization. Ensure that you have considered the things that you do, particularly in a multi-facility scenario. For example, an organization may have 3 facilities; 2 may be textile factories where they manufacture fabric. The third may be a cutting house where the fabric is cut into patterns to be sewn into garments. Think about the environmental issues surrounding these facilities. Since the first 2 facilities are similar and may have a substantial impact on the environment (by creating air emissions, land and waste contamination) and the



cutting house may only contribute to an increase in landfill, the organization may want to include just the two manufacturing facilities in their scope. However, at a later time, they may decide to include the cutting house. Organizations may change their scope as business conditions, regulatory requirements, and business concerns change as long as they involve their registrar in the decision. The scope defines the boundaries of the organization to which your environmental management system will apply and is determined by top management. This is especially important if you have multiple locations and/or processes.

What do we have to do and how can we do it? Read the statement, consider how you would implement the requirement, then read the suggestions

Define and document the scope of your EMS

Have top management determine what facilities are to be included in the environmental management system. Perhaps it will be a single location or maybe two facilities, one in this town and another in the next town over. Then ensure you document this information. An EMS manual would be a good place to define this information. When it comes time to contact a registrar for certification this is one of the first questions he/she will ask. Based on your scope develop, document, implement, maintain and continually improve an EMS that is compliant with the 14001-2004 International Standard. One of the easiest and best ways to demonstrate that you have established an environmental management system is by developing an environmental manual that addresses the requirements of ISO 14001-2004. In the manual you can define your scope, reference related procedures, and describe the main elements of the EMS and how they interact.

4.2 Environmental Policy Discussion: Clause 4.2 states that top management will ensure there is a documented, environmental policy. The requirement states that the policy should contain a commitment to continual improvement and prevention of pollution and it should comply with all of the legal requirements that relate to the organization’s environmental aspects. The policy should be appropriate for the organization depending on its environmental impacts and linked to the organization’s objectives and targets.

The policy must be communicated not only to employees of the organization but to anyone doing work on its behalf, (such as contractors) and it should be made available to the public. The policy must provide a framework for establishing and reviewing environmental objectives. However, other than the required “commitments” there is no



specific guidance for what the policy should contain or how it should be worded except that it should be relevant to the organization.

What do we have to do and how can we do it? Read the statement, consider how you would implement the requirement, then read the suggestions.

Develop an environmental policy, document it and continually review it.

Top management must develop and document the environmental policy as it is a reflection of the company's vision and commitment to the prevention of pollution.

The policy is a living document and should change as your business changes. It is a requirement that the policy be reviewed for continuing suitability. A good time to do this is during management review as it is a requirement of management review that the environmental policy be reviewed!

It doesn't hurt to have top management sign the policy as objective evidence of their commitment!

Ensure you include a commitment to continual improvement, including prevention of pollution.

From the list of requirements for the environmental policy there are a few things that actually have to be in the policy itself. Two of these are the commitment for continual improvement and the commitment to prevent pollution. Ensure there are statements in the policy that reflect these commitments.

Ensure you include a commitment to comply with legal and “other” requirements.

Another required “commitment” is to comply with all of the legal requirements and any other requirements that the organization chooses to comply with. This applies to those requirements that apply to environmental aspects only. This commitment must be documented in the policy.

Ensure the policy sets the stage for establishing and reviewing environmental objectives and targets.

There is no requirement for this wording to be in the policy. As long as you make a commitment to continual improvement, this sets the stage for establishing objectives and targets to accomplish this goal.

Communicate the policy throughout the organization.

The requirement is that the policy be communicated to employees, contractors and anyone else who may be doing work for the organization. You may want to have annual awareness



training where the policy is reviewed with everyone internally. It is probably a good idea to post it in common areas of the facility. An important thing to note here is that your workers are not required to memorize the policy. They need to understand and describe what the policy means to them and how it affects them and their job.

Communicate the policy to non-employees working on behalf of the organization.

The requirement is that you look beyond your own employees and consider other people performing tasks on your behalf that fall within the scope of the EMS. This includes temporary workers and contractors. Consider this: if the organization outsources any “tasks” to another organization and those tasks relate to the environmental aspects of the activities, products or services that are within the scope of the organization’s EMS, how do you communicate your environmental policy to those people? Determine who else needs to understand the policy and develop a way to communicate it to them. You may be able to do this by attaching something to your purchase order.

Ensure the policy is made available to the public. .

Unlike the quality policy required by ISO 9001 the environmental policy required by ISO 14001 must be made available to the public. One option is to post it on your website. Just make sure you remember to revise it there when the policy is revised. If you are thinking about posting it in the lobby that’s a great idea but how is it available to the public when your company is closed? Another option is to include the policy in advertisements or in annual reports.

Next, we will look at the planning that is needed for successful implementation of the environmental management system (EMS).



Lesson D07: Environmental Aspects / Legal and Other Requirements / Objectives, Targets and Programs 4.3 Planning 4.3.1 Environmental Aspects 4.3.2 Legal and Other Requirements 4.3.3 Objectives, Targets and Programs Objectives: The student will be able to:

• Identify environmental aspects • Establish a way to identify legal and other requirements • Develop environmental objectives and targets • Plan how to achieve these objectives

4.3.1 Environmental Aspects

Discussion: Clause 4.3.1 requires that organizations develop a procedure for identifying the environmental aspects of their activities, products and services. These are the same activities, products and services that are covered under the scope of the EMS that has been defined as part of compliance to 4.1. It is recognized that an organization cannot necessarily control all of its aspects, for example it can control how much electricity it uses but it cannot control the generation of electricity from the electric company. Because of this, when identifying environmental aspects, organizations should concentrate on those that it can control. Since this identification is an ongoing process, when organizations plan for new product or service development or incorporate new or modified activities, products or services into their operations, the environmental aspects and impacts of these events must be taken into consideration.

Once environmental aspects have been identified the organization needs to go a step further and identify those aspects that can have a significant impact on the environment. Aspects that can have a significant impact on the environment are called significant aspects. The organization must document its aspects and impacts, including those that are considered significant and this information must be maintained as changes occur.

It is important to ensure that the identification process is effective because once significant environmental aspects have been identified they now become the basis for the rest of the EMS.

Having a proper understanding of environmental aspects and impacts is critical to the implementation of an effective and continually improving EMS.

Cause and effect relationship



The relationship between aspects and impacts is one of cause and effect. An aspect causes an impact. An activity that your organization does, either through its manufacturing process, its services or its product may result in an aspect. The aspect in turn, causes a change to the environment. In other words, it has an effect on the environment. For example, let’s say that your facility is a meat processing plant and one of your processes is the “smoke house.” In order to generate smoke for “smoking” or “curing” you need to create a fire by burning wood. (activity) When you burn wood you create air emissions (aspect) which interact with the environment. The result of these air emissions is air pollution (impact) due to the particle dust in the emissions. These interactions with the environment may happen continuously, sporadically, or only during emergency situations.

One aspect may result in many impacts

These interactions with the environment may happen continuously, sporadically, or only during emergency situations. When identifying your organization’s aspects and impacts, make sure you consider all activities, all aspects for each activity, and all impacts to the environment (good or bad for each aspect) over which you have an influence or can control.

Other recourses

Identifying your organization’s aspects and impacts can be a formidable task. The previous four slides were taken from our class called “Identifying Environmental Aspects and Impacts. This class project style class that walks you through the process of identifying aspects and impacts. The project class includes additional handouts that you can use to identify your own aspects and impacts. This addition detailed information is beyond the scope of this class. If after taking the requirements class, you think more information would be helpful, consider taking the Identifying Environmental Aspects and Impacts class.

What do we have to do and how can we do it? Read the question, consider how you would implement the requirement, then read the suggestions.

Develop a process for identifying environmental aspects. .

The standard requires that the organization have a “procedure” for how it determined and continues to maintain its environmental aspects. This is actually a two part process. The first part is that the organization must initially define its aspects and impacts and the second is that



it must continue to maintain this list. By-the-book, documented procedures are not required, but since the process can be rigorous, I would recommend that you do have this process documented. An auditor will verify that you do have a process for determining your environmental aspects and that you use this process. Even though a documented procedure is not required, documentation reflecting the process is required. You should have some kind of forms indicating the activities, products and services that were considered and how aspects were determined.

Ensure that all of the appropriate inputs and outputs were considered.

While determining aspects don’t forget to consider normal and abnormal operating conditions, and potential emergency situations. Consider such things as air emissions, land contamination, use of raw materials and natural resources and waste generated. Don't forget to consider activities such as design and development, manufacturing processes, waste management and packaging. Ensure your procedure includes how new and planned developments or changes to existing activities, products and services are taken into consideration.

Define how you ensure the aspect and impact information is kept up to date. .

Once the initial evaluation process has been completed the organization must ensure that it keeps track of the factors that may cause a change to its environmental aspects and respond accordingly. This may include a change in legal requirements or perhaps the achievement of an objective. Define this in your procedure and don’t forget to put it into practice!

Define a process for determining which aspects are considered significant and have documentation to support it.

Once the organization has determined all known environmental aspects, it must assign significance to them in order to identify its significant environmental aspects. There must be a procedure for establishing significance and documentation available as objective evidence that an auditor can review for conformance during an audit. This will usually include some sort of “significance rating” scale, where significance is assigned based on factors that are important to the organization such as whether or not federal regulations apply, the severity of the impacts, the frequency and how widespread the impact might be. Management may consider factors such as cost, risk and available technology when determining significance. As your system matures significant aspects should be changing as objectives and targets are achieved.



Now that you have identified your significant environmental aspects you must consider them while developing the rest of the EMS.

Once significant environmental aspects (SEA) have been determined they must be used as the basis for most of the EMS. Areas where SEAs should be reflected are in your objectives and targets, training programs and records to verify that training required for those people whose jobs have the potential to cause a significant environmental impact have been properly trained. Ensure that communication has taken place regarding SEA. Develop operational controls for those operations having a significant environmental impact. These can be work instructions, procedures, forms, etc. Ensure emergency response plans address SEA. Retain monitoring and measuring records to demonstrate that you are measuring the key characteristics of SEA. Don’t be confused by this. We will discuss the actions you need to take for each one of these clauses later in the course. This just serves as a summary of the places in your EMS where you need to consider significant environmental aspects.

4.3.2 Legal and other requirements Discussion: Once again the requirement is to establish, implement and maintain a procedure and as in the previous clauses, a documented procedure is not required. Let’s stop a moment and discuss the difference between a procedure and a documented procedure according to ISO 14001. A documented procedure is a specified way to carry out an activity or process that has been transcribed onto paper, recorded onto an electronic or optical computer disc or captured in photographs, for example.

An undocumented procedure is one which has not been transferred onto one of the media listed and the steps to perform the activity or process have been verbally communicated. The requirement is for an organization to be aware of the legal and other requirements pertaining to its environmental aspects with which it must comply and then decide exactly how to apply these rules and regulations to its identified environmental aspects.

Information about these requirements should be appropriately communicated to everyone doing work for the organization whose actions may affect compliance with any of these rules and regulations.

This knowledge is critical as it affects many elements of the EMS, including some that are explicit and others that are implied!



Legal requirements are any requirements relating to your environments aspects that are issued by a government authority. This may include international, national state / provincial, county and local authorities. These requirements have legal validity and there are usually ramifications for noncompliance.

They may include: • Legislation, statutes and regulations • Decrees and directives • Permits, licenses • Orders issued by regulatory agencies • Court judgments • Treaties

Legal requirements are any requirements relating to your environments aspects that are issued by a government authority. This may include international, national state / provincial, county and local authorities. These requirements have legal validity and there are usually ramifications for noncompliance. They may include:

• Agreements with public authorities • Agreements with customers • Non-regulatory guidelines • Voluntary codes of practice • Requirements from trade associations • Corporate requirements

There are several ways for an organization to keep track of requirements with which it must comply. The government EPA site is a good place to start but don’t forget to check the environmental requirements put in place by your state. Each state has different rules, some stricter than others, regarding environmental compliance. Another good source of information is trade groups or publications that are particular to your organization. There are some companies whose business it is to track upcoming requirements. These companies may deliver this information via the internet or through on-line databases or CDs.


Identify the legal requirements with which your organization must comply.



There must be a process in place for identifying legal and other requirements with which the organization subscribes regarding its environmental aspects and someone must be assigned the responsibility of process owner.

Define how you will access these requirements

This is not a one time deal. The organization must constantly be on top of legal requirements to ensure they identify changes taking place that may affect them. Someone must be accessing and reviewing this information on a regular basis. In some organizations it may be the plant engineer or the EH&S coordinator. Access may be obtained through an internet website or through trade publications or even a consulting firm whose job it is to ensure the organization is informed of all legal requirements as compliance becomes mandatory.

Develop a list of requirements and include international, federal, state, county and local rules and regulations, as applicable.

Though there is no specific requirement to have a list, if you do not, it may be difficult to remember which rules and regulations apply, especially if you have deadlines for the submission of supporting documentation such as chemical inventories and permitting requirements. It may be easy to identify federal regulations but don't forget state and local regulations. Does your local fire department require that you ensure they have in their possession an up to date chemical inventory list in case of a fire at your location? There are different rules for different states and communities. .

Consider these rules and regulations during the implementation of your EMS.

Areas where legal and other requirements should be reflected are in objectives and targets, environmental aspects and impacts identification documentation, emergency preparedness and response procedures, operational controls and training.

4.3.3 Objectives, targets and programs Discussion:

Now that the organization has defined the environmental policy and made the commitment to prevent pollution, comply with legal and other requirements and to continually improve, and has identified significant environmental aspects and identified legal and other requirements with which the organization subscribes, it must take all of these items and use them as a basis for developing and documenting environmental objectives and targets for all relevant functions and levels within the organization. This means that it is not enough for high level objectives to be established, these objectives must cascade down into meaningful objectives for everyone in the organization.

The organization cannot judge whether or not it is reaching its target if it doesn’t measure its progress. Therefore, unless it is not practical, it must develop measurements to ensure it is heading in the proper direction.



The organization is not expected to develop pie in the sky goals that it may never reach. While developing targets the organization must consider what it has available in the form of technology and think about the requirements of the business and how much money it will have to implement improvement objectives. It is also important to consider the views of interested parties. Once the organization has decided on its objectives and targets, it must establish, implement and maintain programs for achieving them. Part of this program should include who has responsibility for ensuring achievement of the target. This may be one person or a functional group, since an objective and target may be found on several levels of the organization. There must also be a plan and time frame for how and when the objective and target will be met.

Remember, targets will change as they are achieved or as business conditions change!

What do we have to do and how do we do it?

Read the statement, consider how you would implement the requirement, then read the suggestions.

Develop and document high and lower level environmental objectives and targets.

You must develop objects and targets that are a reflection of your environmental policy. Your policy describes your organization’s environmental vision and your objectives and targets describe how you will achieve the vision. These are not just casual statements your organization may make to appear “environmentally friendly.” You have to develop plans to accomplish these goals and then monitor your progress. The goals will actually be achieved with the help of all members of the organization. That is why you develop lower level objectives in support of the higher level objectives. This way everyone participates. When establishing goals and objectives don’t try to solve all of your problems at once. Please do not identify any more than seven (7) objectives at any one time. I personally think four (4) is a good number.

While developing objectives consider certain inputs.

Consider reducing waste or the release of specific elements into the air, reducing ground water contamination, reducing use of raw materials by reducing rework and scrap. Ensure your objectives and targets reflect the vision of the policy and are they consistent with the commitments in the policy to prevent pollution, comply with the rules and regulations and continually improve.

Define measurable targets.

If you don’t measure how can you judge whether or not you are improving? Develop measurable targets and track your progress towards achieving them. You can include both



short and long term targets. The standard requires that targets be measureable where practical. If you decide that it is not practical to measure a particular target be prepared to justify your reasoning to an auditor.

Other considerations for setting targets.

While setting targets don't forget to consider your significant impacts, available technology, financial, operational and business requirements. Some targets can be very expensive to implement. Don't set a target whose successful implementation will bankrupt your company! Remember to "consider" the opinions and views of interested parties.

Develop plans for achieving your objectives and targets. .

You MUST have a plan for achieving each objective and target. Make sure the plan includes the person responsible, the time line and how the goal will be reached. Develop lower-level plans as well. Keep track of your progress. If things do not go as planned take corrective action to get back on track.

Ensure people on all levels of your organization understand the objectives and targets and how they contribute to their achievement.

Often it is the people on lower levels who will actually be doing the work to achieve the target. Don’t forget about them. Communicate with them and ensure they understand how they contribute to achieving the objectives and targets. Remember not all people will be affecting all targets. People need to know the details for the one(s) they are trying to achieve. Though not a requirement, It's a good idea to post a chart or graph within the department that illustrates progress towards the goal. It is easier to obtain "buy-in" from people when they actually can see that they are making a difference. Next, we will begin to look at the “Do” part of the Plan, Do, Check, Act continual improvement cycle and learn what it takes to actually implement all of the things that we have been discussing thus far.



Lesson D08: Resources, Roles, Responsibility and Authority/Competence, Training and Awareness 4.4 Implementation and Operation 4.4.1 Resources, Roles, Responsibility and Authority 4.4.2 Competence, Training and Awareness Principle Concepts:

• Management must provide resources to establish, implement and maintain the EMS

• Roles, responsibilities and authorities must be defined, documented and communicated

• People having the potential to cause an environmental impact must be competent

Objectives: The student will be able to:

• Learn the responsibilities of the Management Rep • Define roles, responsibilities, and authorities of those impacting the environment • Develop a training program to address the requirements of the standard

4.4.1 Resources, roles, responsibility and authority

Discussion: This clause is the first clause of the standard aligned with the Do portion of the Plan Do Check Act continual improvement cycle.

The requirement is for management to provide the resources necessary to establish, implement, maintain and improve the environmental management system. In order for the EMS to be successful management should consider human resources and specialized skills that may be needed. When working with an environmental management system it is not uncommon to require people with licenses or certifications to perform, for example, the specialized water testing or air testing that must be done. Resources also include the organizational infrastructure, technology and financial resources.

It is always a good idea to consider the views of interested parties while determining resources that will be needed! A second requirement in this clause is to define and document roles, responsibilities and authorities for managing the EMS. One very important requirement is that not only are roles, responsibilities and authorities defined, but also that they are communicated. While you are being audited you do not want an auditor to speak to someone in the



organization only to find out that they are not aware they are responsible for something that management has delegated to them. The last requirement of this clause requires top management to appoint a specific management representative who has the responsibility and authority for the environmental management system. The appointed representative has responsibility and authority for establishing, implementing, and maintaining the environmental management system in accordance with the ISO 14001 standard. The representative is also responsible for reporting on environmental system performance to top management. The report can be input for management review meetings or any other means to report performance as long as the information gets to top management.

Provide and allocate resources Resources must be provided in a timely and efficient manner and resource allocation should consider current and future needs of the organization. Resources and their allocation should be reviewed periodically and consideration given to planned changes.

What do we have to do and how do we do it? Read the statement, consider how you would implement the requirement, then read the suggestions.

Management must define how they ensure that the necessary resources for establishing, implementing and maintaining the EMS are made available.

Management must develop a way to identify resource needs and provide human, technological and financial resources. Resources should include organizational infrastructure and must be provided so employees have what they need to do their job and to effectively implement and maintain the EMS. Identifying needs could be based on the organization’s strategic or business plan. While speaking with management I have heard them say something like “the group gets together and using input from department managers as well, determines what will be needed for the next year and sometimes 5 years out.” During an audit, management should be prepared to give an example of how they identified and provided for a resource need, particularly one that relates to the EMS.

Roles, Responsibility and Authority Successful establishment, implementation and maintenance of an environmental management system depends to a great extent on how top management defines and assigns responsibilities and authority within the organization. (ISO 14004-2004)

The organization must define, document and communicate the responsibilities and authorities of the people doing work on its behalf whose work relates to the EMS.



Remember, environmental responsibilities are not confined to the environmental function but can include other areas of the organization as well. The resources provided by top management should enable the people to fulfill their responsibilities and responsibilities should be reviewed when there is a change in the organization.

What so we have to do and how do we do it? Read the statement, consider how you would implement the requirement, then read the suggestions.

Management must define, document and communicate responsibilities and authorities.

This can be accomplished by using an organizational chart, job descriptions or procedures. Be careful if you choose to use ONLY an organizational chart. There are some very specific and important responsibilities that may not show up on a typical organizational chart. For example, ensure you define who has responsibility for identifying aspects and impacts and maintaining this information, maintaining legal and other requirements, identifying and developing training needs and who is responsible for responding to environmental emergencies. Ensure that everyone is aware of their responsibilities regarding the EMS. Communication may take place during “all hands” meetings or meetings between managers and their reports. Everyone must know who the environmental management representative is.

Top management must appoint someone as the Environmental Management Representative.

The environmental management representative is the cheerleader for the EMS. This person MUST have the authority and resources to carry out his/her responsibilities for ensuring that the EMS is being implemented effectively and reporting to top management on the performance of the EMS. Because of these responsibilities the management representative must be high enough up on the food chain so everyone will listen when he/she speaks. Make sure the environmental management representative knows what his/her responsibilities are regarding the EMS. Communication regarding the effectiveness of the EMS and opportunities for improvement can take place during management review. However, if something important comes up that requires management's immediate attention, don't wait for the next management review to bring it to management's attention!

4.4.2 Competence, training and awareness Discussion:



Personnel performing tasks for the organization or on its behalf that could cause a significant environmental impact must be competent. Competence denotes having acquired (and using) one's formal education, training, skills, and experience. This is an overall system requirement to ensure the organization takes responsibility for competency of people. When people are selected for a position, consideration should be given to individual education, training, skills, and experience necessary to carry out the duties of the position. Most organizations have position requirements or a position description that includes individual requirements (such as years of formal education and prior work experience). The organization must determine the training associated with its environmental aspects and the environmental management system and then deliver it. Several factors should be considered while making these decisions such as:

• Changes to regulations • Process changes • New methods • Changing significant aspects and impacts • Changes to goals and targets • Individual work experience • Individual transfers or promotions

Training: When developing training programs consider:

• Awareness training • Hazard communication training • Waste management training • Wastewater treatment facility training • Emergency response training • Special skills-development training

4.4.2 Competence, training and awareness

Discussion: The organization must ensure that all persons working on behalf of the organization are aware of:

1. The importance of conforming to the environment policy and the requirements of the EMS

2. Their roles and responsibilities within the EMS 3. The significant actual or potential environmental aspects and associated impacts

of their work activities and the benefits of improved performance 4. The consequences of the departure from applicable end requirements

What do we have to do and how do we do it?




Determine which tasks may cause or potentially cause a significant environmental impact.

Since training must be given to those people whose jobs may cause or potentially cause an environmental impact it is important that those tasks and the people performing them are identified for training purposes. You must have a way to identify these tasks. Since the decision to deliver training is based on significant environmental aspects and impacts you can identify the operations and tasks associated with significant environmental aspects and impacts and ensure you have a training plan for the people doing those operations and tasks. Identify those people that are currently performing those operations and tasks and train them. As new people enter the organization to perform those operations or tasks ensure you train them as well.

Implement required training.

Once the task has been identified, the required training must then be developed and delivered. It is possible that training required for two different people doing the same task might be different. This is because personnel may already have previous training, certifications, work experience, or education. Implement a formal training program. There may be skills that require periodic training. For example, Hazcom training is usually given every year even to those that have already been trained. If you have such training, ensure you provide for its scheduling and delivery. Ensure employee files contain records of training, education levels, professional licenses, etc. as objective evidence that they are competent to do the task.

Train temporary and contract employees.

It's easy to develop and deliver training programs for full-time employees because they are under the control of the organization. But it is just as important to ensure that temporary workers or contractors have the training they need before performing tasks on the organization's behalf. The effect that they can have on the environment is not based on their employment status; it is based on the tasks they are performing. Don't forget to train them and keep records that you did!

Define the types of training your organization will deliver

Although it is up to you to determine the types of training you need to give, consider such things as awareness training, hazard communication training, waste management, waste water treatment facility training, emergency response training, and perhaps some special skills and personal development training. Remember the training is based on the scope of the EMS.



Prepare materials for "Awareness" training and deliver it.

Awareness training materials should emphasize the importance of conforming with the environmental policy and procedures and with the requirements of the EMS. They must also contain information regarding the consequences of not conforming with specified procedures. Remember to keep records of the people that attended this training.

Ensure that people working for or on behalf of the organization understand the environmental policy, objectives and the importance of their jobs.

Employees on all levels must understand how their job affects the environmental policy and the achievement of environmental objectives and what happens if they do not perform their job properly. They should be able to speak to the training they have received and how often they receive it. For example, ensure that first-aid responders have had the proper training, their certifications are current and they understand their responsibilities. Make sure people understand the significance of their work as it relates to aspects and impacts. Everyone must understand and be able to describe the benefits of improved personal performance and the potential consequences of not following procedures. Next, we will continue through the "Do" part of the Plan, Do, Check, Act continual improvement cycle learning about documentation and communication.



Lesson D09: Communication/Documentation/ Control of Documents 4.4.3 Communication 4.4.4 Documentation 4.4.5 Control of Documents Principle Concepts:

• Establish methods to communicate internally and externally • Develop the required documentation • Control documentation

Objectives: The student will be able to:

• Learn methods of internal/external communication • Determine when documentation is needed • Determine how documents are controlled

4.4.3 Communication

Discussion:

Communication throughout all levels of an organization is critical to having an effective EMS. Communication helps facilitate for example, problem solving, coordinating activities and follow-up on action plans. When people feel they are involved they become more motivated and are more likely to accept the improvement efforts of the organization. Organizations should have a method in place for receiving feedback from employees and should encourage it. They should also post progress towards objectives and targets. People are more involved when they can actually see the fruits of their efforts.

Communication with external parties can be an important and effective tool for environmental management. It can promote acceptance of the organization’s efforts and initiate dialogue with interested parties. At a minimum an organization must have a process for receiving, documenting and responding to relevant communications from external parties. An organization should have a way to communicate with external parities in emergency situations that may affect them. Additionally the organization must decide whether or not to communicate externally regarding its significant environmental aspects and then document this decision. If the organization does decide to communicate externally, then it must develop a procedure to address this.

How do we develop effective methods of communication?



Define your audience (internal and external) and what they need to know.

Decide how you can best reach them.

What do we need to do and how can we do it? Read each statement, consider how you would implement the requirement, then read the suggestions.

.

Develop a way to ensure information regarding environmental aspects and the EMS is communicated internally.

Typical methods of communication include bulletin boards, initial training, periodic meetings and newsletters. Don’t forget to communicate regarding objectives and targets and progress towards them. Develop a way for employees to discuss environmental issues with management. This would probably start with the environmental management representative. Remember, when you are audited the auditor will determine your method for communicating with everyone and then speak to people to ensure the communication actually occurred and that people understood what they heard.

Define how external inquiries are received and addressed.

The organization must have a way to receive, document, and respond to communications from external interested parties. When the phone rings and the front desk answers who should receive that call? Make sure responsibility for handling external inquiries is defined and the person responsible for receiving the call is aware of his/her responsibility. It is possible that basic questions may be answered by the environmental management representative, however legal issues may go directly to someone in top management or even the legal department. Since external communications must be documented, the best thing to do is develop a form to record phone calls. Retaining emails will suffice as a record of email inquires. Remember, records must include information related to receiving the call and HOW you responded.

Management must decide whether or not to communicate externally regarding significant environmental aspects and then record the decision.

The organization must decide whether or not to communicate externally regarding their significant environmental aspects and document that decision. An EMS manual would be a good place to record it. Some organizations state that they will decide whether or not to communicate externally regarding significant environmental aspects on a case by case basis. If they’ve done something especially environmentally friendly, such as reduce greenhouse gas emissions, they may want to let everyone know about it and even write an article for the local newspaper. If you do decide to communicate externally regarding your significant environmental aspects, you must develop a method for communicating and then make sure you follow the procedure.



4.4.4 Documentation Discussion:

The standard provides two test criteria as guidance for determining if documents are needed.

The first one is:

When the standard requires it, such as: • Environmental policy, objectives and targets • Description of the scope of the EMS • Description of the main elements of the EMS and their interaction • Specified documents • Specified records

The second one is: When documents are needed to ensure effective planning, operation, and control of processes that relate to its significant environmental aspects.

The phrase effective planning, operation, and control is very important in determining when documents are needed as we will see a bit later.

If a document is required per the two above criteria, the documents must be controlled under clause 4.4.5.

Below is a list of documentation required by the standard: 4.1 Documented scope of the EMS 4.2 Documented environmental policy 4.3.1 Documented environmental aspects and impacts 4.3.3 Documented objectives and targets 4.4.1 Documented roles, responsibilities and authorities 4.4.3 Communication from external parties 4.4.3 Decision to communicate externally regarding environmental aspects 4.4.4 Description of the main elements of the EMS 4.4.6 Procedures for operational control 4.5.1 Documenting of information to monitor performance, applicable operational controls and conformity with the organization’s environmental objectives and targets

What do we have to do and how can we do it? Read the question or statement, think about the evidence you would need, then read the explanation.

Ensue you have the documents required by ISO 14001-2004.



Review the standard and ensure you have all of the required documentation. This includes the documented environmental policy, objectives and targets as well as a documented description of the scope of the EMS. Describe the main elements of the EMS and their interaction. This could be in the form of an EMS manual, flowchart or process diagram. Don't forget documented aspects and how they were identified (4.3.1), documented roles, responsibilities and authorities, (4.4.1) and records of competence, training and awareness (4.4.2), for example.

Determine what other documentation you need to maintain the EMS.

There are lots of other documents that you need to have an effective EMS including permits, international, federal, state and local regulatory requirements and other external documents such as the ISO 14001-2004 Standard. Don’t forget your procedures, work instructions, forms and records. It is probably a good idea to make a list of all of the documents you have, especially in view of the requirements in next clause which is called document control. How can you control documents if you don’t know what they?

4.4.5 Control of Documents Discussion: Required documents must be controlled (in any medium or type) in accordance with a procedure. Except for the requirement in 4.4.6 (to establish, implement and maintain documented procedures to control situations where their absence could lead to deviation from the environmental policy, objectives and targets), the organization determines what documented procedures are required to effectively manage the environmental management system (clause 4.4.4). The specific document control requirements are:

• Documents must be approved for adequacy prior to release or issue (Any competent authority should be able to approve documents)

• Documents should be reviewed, updated and re-approved as necessary • Document versions must be identified • Documents must be available at points of use • Documents must be legible and easily identified • External documents must be identified and their distribution controlled • Identification or markings must be applied to prevent unintended use of obsolete

documents

What do we have to do and how can we do it?

Read the statement, consider how you would address the requirement, then read the suggestions.



Develop and maintain a procedure for controlling EMS documents and records.

Define how you determine who is responsible for approving documents prior to use. The approver could be identified by title or person's name and should probably be on the documentso people know that the document has been approved for use. Define how you review, update and re-approve documents. This is usually done by the same function that originally issued the document. You will want to have a revision number on your documents to ensure everyone is using the proper revision. Keep track of this by recording the revision number on your document control master list. If documents are on the computer it’s relatively easy to ensure they stay legible. For hard copy documents define the measures taken to ensure they remain legible.

Implement the procedure.

Make sure the revision levels on the documents themselves match the revision levels on your document list. Ensure people can access the documents they need. If documents are stored on the computer users will need access to the computer. Make sure the documents are approved and by the proper function according to your procedure. During an audit, an auditor may ask someone to show them a document to which they need access. Make sure they can get to it! Address control of external documents and the removal of obsolete documents. External documents are documents you use but didn’t write. The key here is distribution. We want to ensure that when the ISO 14001-2004 standard, for example, is revised, that the people who currently have a copy, get a copy of the new revision and the old version is removed. On your document master list, record who has each external document and the current revision level. This way when a new version of the document is published you can identify who should receive the updated version. External documents may include federal and state rules and regulations, other regulations and ISO 14001-2004, etc. Obsolete documents need to be disposed of or stored and identified as obsolete, so an old version will not be mistakenly used. If you are going to keep obsolete versions of documents, stamp them with an “obsolete” stamp. Once again follow through and make sure whatever process you describe is also implemented. Next, we will continue through the “Do” part of the Plan, Do, Check, Act continual improvement cycle learning about controlling operations and preparing for emergencies.



Lesson D10: Operational Control/Emergency Preparedness and Response 4.4.6 Operational Control 4.4.7 Emergency Preparedness and Response Objectives: The student will be able to:

• Identify operations that are associated with environmental aspects • Control those operations using documented procedures • Identify potential emergency situations and the response

4.4.6 Operational Control

Discussion:

Operational control is all about building environmental performance into operations and activities.

To ensure that you satisfy the commitments in your environmental policy, objectives and targets, certain activities must be controlled. When operations or activities are complex and/or the potential environmental impacts are significant, controls must include documented procedures.

Determining which operations or activities require documented procedures and how they should be controlled is critical in designing and implementing an effective EMS. Remember, you may need to establish operational controls to manage significant environmental aspects or legal requirements regardless of whether or not they have objectives and targets.

While determining which operations and activities need to be controlled, look beyond routine production or service. Activities such as equipment maintenance, management of off-site contractors and services provided by suppliers or vendors could affect your organization’s environmental performance significantly.

Determine operational controls

Operational controls can take the form of procedures, work instructions, physical controls, trained personnel or any combination thereof. It depends on the complexity of the activity, the skill of the employees and the environmental significance of the operation itself. One approach to establishing operational controls is to:

1. Choose a method of control 2. Select acceptable operating criteria



3. Establish procedures where needed that define how the operations are to be planned, carried out and controlled.

4. Document the procedures in the form of instructions, signs, forms, visual aids, etc.



Determine which activities need operational controls, develop documented operating procedures and implement the procedures.

Remember documented operational controls such as procedures are only required for certain operations. You must decide which ones. Think about those operations that are associated with significant environmental aspects. Begin by looking at your environmental aspects and legal regulations to determine what activities are related to them. Work with the people involved in these activities to determine what is critical to the successful control of environmental impacts. Consider the risk and complexity of the activity and how much supervision will be available along with the skill and training of the operators. We want to ensure that everyone is performing the operation the same way and taking the same precautions, if applicable. Develop documented procedures, diagrams, work instructions, and forms to control operations where their absence could cause deviation from the environmental policy, objectives and targets. Include the necessary operating criteria and ensure the appropriate people have access to these work instructions/procedures. Lastly, ensure the people performing the tasks follow the instructions. .

Develop a procedure directing the purchase of goods and services related to the identified significant environmental aspects.

Define how information regarding significant environmental aspects will be communicated to suppliers and subcontractors.

• You may want to keep a list of goods and services related to identifiable environmental aspects provided by suppliers and contractors. If you are using a computerized purchasing database perhaps you can add a code to items or suppliers indicating that they may have a significant environmental impact.

• Define what you expect from suppliers and contractors and then develop a way to tell them. For example, if someone is hired to paint your facility you may want to ensure they use water based latex paints. If the application requires oil based paint you want to ensure they don’t clean their oil based paint tools in the sink or dispose of their paint



cans in the garbage. Either of these aspects could impact the environment by potentially contaminating the soil and/or water supply.

• One way to deliver this information is by including it on the purchase order. Another way is to include an attachment to the purchase order explaining your policies. .

Once you develop a process, stick to it!

4.4.7 Emergency preparedness and response Discussion:

The organization must have a process in place for identifying potential emergency situations and potential accidents that can have an impact on the environment. Once that has been accomplished the organization must have a plan for responding to these potential emergency situations.

When an organization is trying to identify the potential emergency situations and accidents that may have adverse environmental impacts, consideration should be given to:

• Accidental emissions to the air • Accidental discharges to the land and water • The extent of the environmental impacts that could occur

Respond to emergencies

When developing your emergency response plans, it is important to design something that you can actually use in an emergency since it is a requirement of the standard that you RESPOND to emergency situations to try and minimize the adverse environmental impacts.

The third important part of this requirement is for the organization to review and revise its emergency plans as necessary, particularly after an incident occurs, and test the plans whenever possible. Despite an organization's best efforts, there is still the possibility for an accident or emergency situation to occur. By developing effective emergency preparedness and response plans, the organization can lessen the impact and injuries, protect employees and neighbors and reduce clean up and down time. When developing an emergency response plan, the organization must first identify those potential emergency situations that can have an adverse impact on the



environment. The next step is to develop an appropriate response to mitigate the damage. An effective program should include:

• Assessing the potential for accidents and emergencies • Preventing incidents and their associated environmental impacts • Developing plans for responding to incidents to mitigate the impact • Periodically retesting these plans and making improvements


Identify operations that could result in accidents or emergency situations.

This shouldn't be too difficult as you have already identified those operations that could cause an environmental impact and you have identified your legal obligations. If there is a regulation pertaining to an aspect, chances are there is a potential for an emergency situation.

Prepare written accident / emergency response plans. . Identify, define and document response mechanisms for potential emergency situations. Ensure employees know what to do in the event of an accident or emergency situation. Assign and document responsibilities for handling accidents and emergency situations, train emergency response employees and refresh training as applicable. Retain records of this training. Post emergency procedures and evacuation plans throughout the facility and clearly identify emergency equipment. Part of your plan should be to define how the organization communicates with local, state and federal emergency response agencies regarding accidents and emergencies. Ensure emergency plans include lists and locations of emergency equipment and legal reporting requirements.

Define when emergency procedures are reviewed and revised. You are required to retain records of emergency incidents. Use these records to revise written plans after accidents or emergency situations occur. While reviewing the plans consider what went well and what did not work. Modify actions that did not produce the expected results.

Test emergency plans, if practical and review and update them on a regular basis.



Conduct drills and tests of emergency equipment as well as emergency plans and retain those records. Develop a schedule for maintaining emergency equipment, i.e. fire extinguishers, oxygen masks, etc.

Next, we will begin to look at the "Check" part of the Plan, Do, Check, Act continual improvement cycle and learn how we will measure the performance of the EMS.



Lesson D11: Monitoring and Measurement / Evaluation of Compliance 4. 5 Checking 4.5.1 Monitoring and Measurement 4.5.2 Evaluation of Compliance Objectives: The student will be able to:

• Identify operations that are associated with environmental aspects • Monitor and measure them on a regular basis • Develop a calibration process for equipment used to make measurements • Evaluate compliance to legal and other requirements

4.5 Checking

4.5.1 Monitoring and Measurement Discussion:

If you can't measure it, you can't manage it! Peter Drucker Management Expert

Organizations must establish, implement and maintain procedures to monitor and measure environmental performance on a regular basis.

What should be measured? The standard uses the term key characteristics and states that the organization shall monitor the key characteristics of its operations that can have a significant environmental impact. Although a documented procedure is not required, the documenting of information to monitor performance, applicable operational controls and conformity with the organizational environmental objectives and targets is required. Key characteristics are defined by the organization and may be different for each organization. The organization should consider its significant impacts and then consider how it measures the control it has placed on them. This certainly applies to objectives and targets. For example, if you are trying to reduce your use of a natural resource, water for example, then you need to monitor how much water you are using.

But key characteristics are not limited to only the controls placed on objectives and targets. You may need to measure the effectiveness of operational controls. For example, if you have a boiler permit that limits the amount of emissions from your stack, you better be monitoring that as a key characteristic!

Verify controls



Remember, not all controls are related to production operations! Some of the measurements that we might expect to see may include:

• Volume of waste water discharged • Amount of contaminates at outflow • Pounds of VOC emitted per unit of production • Pounds of hazardous waste generated per year • Energy use per unit of production • Percentage of solid waste recycled / re-used • Pounds of waste oil generated • Pounds of process waste generated • Number of internal audits conducted • Percentage of employees completing training • Average number of days for resolving corrective actions

Verify measures are ongoing

Organizations must have a process in place to ensure these measurements are obtained on a regular basis. Remember, not all controls are related to production operations! A measurement matrix plan may include:

• Measurement - What is being measured • Frequency - When the measurement will be taken • Method - How the measurement will be taken • Responsibility - Who will take the measurement • Record - Where it will be recorded / reported

Calibration

Another very important requirement of this clause is for the organization to use calibrated or verified monitoring and measurement equipment for making these measurements, and to keep records.

Calibration is the setting or correcting of a measuring device or base level, usually by adjusting it to match or conform to a dependably known and unvarying measure. In order to have confidence in the measurements taken to demonstrate that the controls in place are performing adequately, management must plan and then control all aspects of measurement. There must be equipment to test for the parameters and key characteristics identified. The equipment used to conduct the test must be capable of providing a measurement result within specified ranges or tolerances. The measuring and monitoring devices must be maintained in a proper environment. Test and



calibration equipment and standards should be properly stored to protect from damage or deterioration. Organizations must have a process for ensuring that their monitoring and measurement equipment is capable of making the measurements necessary.


Develop a procedure for monitoring and measuring the key characteristics of your organization.

Develop a procedure for identifying key characteristics and how they will be measured. Define what data will be collected and how and include responsibility for monitoring and measuring each one.

• When identifying key characteristics think about such things as requirements for air emission permits, including boiler stacks, amount of chemicals consumed, amounts of hazardous and/or non hazardous waste generated and water usage amounts, as applicable.

• Ensure employees know the monitoring and measuring for which they are responsible.

• Document how you will monitor performance and retain monitoring and measurement records.

• Remember what you measure is based on your significant aspects!

Determine what devices are needed for monitoring and measuring and calibrate them.

Look for a list of equipment to be calibrated, a calibration schedule and calibration records. Look for calibration stickers indicating devices have been calibrated. Who does the calibrations? Are they qualified? How do you know? Verify devices are being calibrated according to the schedule. How are devices protected? Do measuring devices include such things as:

• flow meters (air, water) • tank level gauges and alarms (bulk chemical) • gauges to measure stack flow (air)



4.5.2 Evaluation of compliance 4.5.2.1 Legal Requirements

Discussion:

Determining compliance to the legal requirements related to your environmental aspects and impacts on a regular basis is very important. What you are trying to do is develop a process to identify, correct and prevent violations. The effectiveness of this process should be assessed during management review (4.6) The EPA encourages systematic discovery of regulatory violations. This means that you detect potential violations through environmental audits or compliance management systems that show due diligence in preventing, detecting and correcting violations, and you keep records of the evaluations.

To qualify as systematic discovery, the violation must be discovered through an environmental audit, which is defined as a systematic, documented, periodic and objective review of facility operations and practices related to meeting environmental requirements, or through a compliance management system, which is defined in the Audit Policy.

What do we need to do and how can we do it? Read the statement, consider how you would implement the requirement, then read the suggestions.

Monitor regulatory compliance to ensure compliance with regulations.

You must have a process for evaluating regulatory compliance. This is different from the internal auditing you do to ensure the effectiveness of the EMS. The purpose of this evaluation is to ensure that you are complying with the rules and regulations with which you must comply. You are looking for answers to questions such as “Did you send that report to the state on time?” “Did you file that permit application to the EPA on time?” Keep records of these “periodic evaluations.” You have to know what the requirements are before you can determine compliance to them. To do this you need to identify those rules and regulations with which you must comply. If you implemented 4.3.2 correctly, that part is already done. Whoever is in charge of maintaining legal requirements should have this information. After you perform your compliance evaluation, report your results to management just as you report conformance audit results but don’t wait until management review. Even though compliance evaluations must be input to management review, if your organization has neglected to fulfill a legal obligation, management needs to know immediately!! As part of your process, describe the actions you will take if a regulatory non-compliance is discovered.



Just as it is important to evaluate compliance with legal requirements, an organization must evaluate compliance to the other requirements that it has chosen to comply with. You may conduct this evaluation in the same manner as you do the evaluation of legal requirements or you can have a separate procedure. Other requirements can include such things found in:

• Chemical Industry’s Responsible Care • Petroleum industry’s STEP • PERI – Public Environmental Report Initiative • West Michigan Furniture Industry Council’s Initiative



Evaluate compliance to "other" requirements with which you comply

If you have “other” requirements, you must evaluate compliance to them as well. You can do this the same way you evaluate compliance to legal requirements. As a matter of fact, why not do it at the same time!

Next, we will continue to review the Check part of the Plan, Do, Check, Act continual improvement cycle and learn more about how we measure the performance of the EMS.



Lesson D12: Corrective and Preventive Action/Control of Records 4.5.3 Nonconformity, Corrective Action and Preventive Action 4.5.4 Control of Records Objectives: The student will be able to:

• Deal with actual and potential nonconformities • Maintain and manage records

4.5.3 Nonconformity, Corrective and Preventive Action

Discussion:

In order for an EMS to continue to be effective and improve, organizations must have procedures for identifying actual and potential nonconformities and taking corrective or preventive actions to correct the nonconformity and prevent it from recurring or prevent it from happening in the first place.

Corrective and preventive actions Despite an organization's best efforts there will still be instances when nonconformances do happen. The difference between corrective action and preventive action is that a corrective action is issued when addressing a nonconformance that has already happened in order to prevent its recurrence, while a preventive action is action taken before a nonconformance is discovered in order to prevent occurrence. The standard requires that we have a procedure, but unlike ISO 9001, the requirement for a documented procedure is not called out here. However, remember that we do have a requirement for documented procedures under operational controls (4.4.6). This just may be a situation where the rule for operational controls should apply and a documented procedure may be warranted.

When a nonconformance has been identified we must investigate the cause so we can focus our efforts on the appropriate part of the system. Steps for performing corrective action.

• Identify the problem • Investigate to identify the root cause • Come up with solution • Implement the solution • Document the solution



• Communicate the solution • Evaluate the effectiveness of the solution

Preventive action occurs when a potential problem is identified but there is no actual nonconformance. Preventive action can also be viewed as risk mitigation. Once a risk is identified, if you address the situation before it becomes a problem, it will generally cost less than if you wait for it to develop into a problem before taking action. The steps are similar for preventive action as for corrective action. Steps for performing preventive action.

• Identify the potential problem • Investigate what might cause this to happen • Come up with solution • Implement the solution • Document the solution • Communicate the solution • Evaluate the effectiveness of the solution

Remember: It is just as important to evaluate the effectiveness of preventive actions as it is for corrective actions!


Develop a procedure for dealing with nonconformities and taking corrective action.

Define how nonconformities are identified. Possible sources for data include failure to meet objectives and targets, audit nonconformances, regulatory noncompliances, stakeholder complaints and supplier issues. Define how nonconformities will be addressed, including how the decision is made to take immediate action to mitigate environmental impacts and responsibility for handling them. Retain records of nonconformities that include the results of the action taken. Make sure employees know how to recognize nonconformities and what to do with this information.

Define a process for investigating nonconformities, determining the root cause(s) and taking actions in order to prevent their recurrence.



Describe your process for determining the root cause of the problem, how you develop a plan to address the root cause and how you implement long term corrective action to eliminate the cause of the nonconformities. As part of the process describe how responsibility is delegated for dealing with corrective actions throughout all levels of the organization.

Make plans for loss prevention and risk mitigation.

Preventive action means identifying potential problems and taking action to prevent them from occurring in the first place. Particularly in an EMS this can be considered loss prevention and risk mitigation. Develop loss prevention and risk mitigation plans and apply them to processes, activities and products to mitigate the loss to the organization and avoid potential hazardous conditions. Another way to identify potential preventive actions is by reviewing your organization’s trends and past history. Define how you determine which, of the possible preventive actions, you will act upon. After potential nonconformities have been identified, define how you determine the action to take to prevent them from occurring, including responsibility for implementing and taking required action.

And finally follow your process and initiate some preventive actions!

Keep records

As part of your process define responsibility for creating and retaining records and ensure your records include the results of the preventive or corrective actions taken. Define how corrective and/or preventive actions are closed. As we have already seen earlier in this lesson, evaluating the effectiveness of corrective and preventive actions is not only a requirement but is necessary to determine whether or not the actions taken actually took care of the problem. Corrective and preventive actions should not be considered closed until follow up to determine the effectiveness of the actions taken has been successfully completed. Define responsibility for follow up and for retaining the associated records.

Take actions based on the magnitude of the problem.



Obviously corrective and/or preventive actions are going to address situations that run from being very minor to very severe in their impact or potential impact. The actions you take should be based on the severity of the impact. You could use a system to rate corrective and preventive actions as to their severity. For example, if one procedure is missing the revision level this may be considered minor. If you haven't been performing compliance evaluations, this may be considered major. However you decide to assign risk to corrective and/or preventive actions, ensure you implement the process as defined in your procedure. When changes are made as a result of corrective and preventive actions, ensure these changes are incorporated into procedures, work instructions and other documents. .

4.5.4 Control of Records

Discussion: The value of records management is fairly simple. You must be able to demonstrate that your organization is actually implementing the EMS as it was designed. Records have value internally over time but you may need to have records to provide evidence of effective implementation to external parties such as:

• Customers • A registrar • Federal, state and local agencies • The public

An effective records management program is very straight forward. You need to decide what records to keep, how you will keep them and for how long. You also need to consider how you will dispose of them when you no longer need them. Records may be kept in any form that works for the organization such as hard copy or electronically.

Records

The standard specifically requires the following records. Every organization must have them: 4.4.2 Competence, training and awareness 4.5.1 Monitoring and measurement 4.5.2.1 Evaluation of compliance to legal requirements 4.5.2.2 Evaluation of compliance to other requirements 4.5.3 Nonconformity, corrective action and preventive action 4.5.5 Internal Audit 4.6 Management review

What do we need to do and how can we do it?




Determine which records you need to keep

It’s a good idea to have a list of all of your EMS records to make it easier for you to keep track of them. While attempting to figure out what records you have, think about results of compliance evaluations, permits, corrective and preventive actions, records of competence, records that legal requirements have been fulfilled, training and awareness, internal audits, management review, results of monitoring and measuring, and progress towards objectives and targets.

Develop a procedure for control of records. In your procedure define your controls for identification, storage, protection, retrieval, retention and disposal of records. Define how retention is determined. Consider federal, state or local requirements. Describe your storage and retrieval systems. Some records may be stored on the computer while others may be stored in file cabinets. You want to ensure that records will not be damaged and remain legible. In other words do not store paper records in a cardboard box next to the chimney! Establish retention times for each type of record. You want to avoid establishing the same retention time across the board for all records. For example, perhaps based on legal requirements you state that all records are retained for seven years. However, do you really keep your employee training records for only seven years if the employee is still employed? Make sure you keep your records for the appropriate time frame. Finally, what do you do with records when they have passed their retention time? Some records can be thrown away or recycled, but other more confidential records may need to be shredded.

Next, we will finish up the "Check" part of the Plan, Do, Check, Act continual improvement cycle and review the final element of the cycle, "Act".



Lesson D13: Internal Audit / Management Review This lesson is medium length and concludes the discussion of the measurement (Check) section of the standard and completes the continual improvement cycle by discussing the Act portion of the Plan, Do, Check Act continual improvement cycle.

4 5.5 Internal Audit 4.6 Management Review Objectives: The student will be able to:

• Implement an internal audit program to determine conformance to the standard and to the EMS

• Learn top management's responsibility in periodically reviewing and improving the health of the EMS

4.5.5 Internal Audit

Discussion:

Audits must be conducted at planned intervals (scheduled) to determine if the environmental management system conforms to (is in compliance with) planned arrangements, EMS requirements, and the requirements of ISO 14001, and that it has been effectively implemented and maintained. It is clear that auditors should audit against the ISO 14001 requirements, and the organization's EMS. Additionally, the implementation and on-going maintenance of conformance to requirements must be assessed. The standard requires that the organization determines conformance of the EMS to planned arrangements. Even though "planned arrangements" is somewhat of an awkward term, most interpret it to mean the procedures (documented or not) that make up the environmental management system. In smaller organizations periodic audits can be particularly valuable. Often times managers are so close to the work performed that they may not see problems or bad habits that may have developed. Periodic EMS audits help ensure that all of the requirements of the EMS have been addressed, implemented and maintained.

The audit program process In order for the EMS audit program to be effective the organization must:

Results of audits should be linked to corrective and preventive actions and should be input to management review to help management maintain focus on the environmental



management system to improve the EMS and its performance and ensure it remains cost effective.

The auditors Auditors must be selected in ways that ensure impartiality and objectivity of the audit results. Internal auditors must have some level of independence or no invested interest in the area being audited. Practicality and the nature of the organization must be considered when determining the level of independence to ensure impartiality and objectivity. A small organization with less severe impacts may not need the same level of independence as a large, complex organization that has many environmentally high risk aspects. Auditors can verify that follow-up actions were taken to address nonconformities. However, there is no requirement in this clause to verify the effectiveness of the action or corrective action as a result of the audit. The effectiveness of corrective actions should be addressed as part of the corrective action review (clause 4.5.3) and management review (clause 4.6).

What do we have to do and how can we do it? Read the question or statement, think about the evidence you would need, then read the explanation.

Conduct internal audits.

You must conduct internal audits to ensure your organization is compliant with the ISO 14001-2004 standard, compliant with your own internal policies and procedures and to ensure your EMS has been properly implemented, maintained, and is effective. Ensure your audits are used as a management tool to determine the strengths and weaknesses of the environmental management system and identify opportunities for improvement. Ensure audit results are used as input to management reviews

Plan and schedule audits and conduct them according to the schedule .

Define how the audit schedule is determined, taking into consideration previous audits and environmental importance. These two factors may indicate particular areas that should be audited more frequently. Develop an audit plan that is consistent with this process, particularly concerning those areas of high environmental importance. Ensure you conduct audits according to the schedule.

Develop a procedure that governs the planning, conduct and reporting of internal audits



Define how audits are planned and conducted and how the results are reported. Include responsibility for planning, conducting, reporting on and retaining records for the audits. Your organization may have an audit manager whose responsibility it is to mange the audit program and schedule internal audits. All audits must have defined audit criteria, scope, and a method for conducting the audit. Describe who has responsibility for defining these items. You may choose to use an audit checklist to aid in the planning and conduct of audits. Ensure criteria includes the ISO 14001-2004 standard, internal procedures, regulatory requirements, and voluntary requirements. Make sure you train your auditors before asking them to conduct audits. Many organizations make the mistake of thinking that it is easy to perform an internal audit and no training should be necessary. Do not fall into this trap. An effective audit requires an effective auditor. Do not leave your auditors to fend for themselves and then complain that audits are a waste of time. Retain audit records!

Make sure that auditors are impartial

Avoid conflict of interest by ensuring you do not assign auditors to audit their own work. For example, if the document control clerk is also an auditor, do not assign him/her to audit document control. This could be seen as a conflict of interest and would result in a nonconformance when the external auditor came to audit.

4.6 Management Review

Discussion:

Top management (the individual or group who directs and controls an organization at the highest level) must review the system for continuing suitability, adequacy, and effectiveness on a scheduled basis (planned intervals). Top management must determine (evaluate) the need for changing (improving) the quality management system (i.e., change of policy, objectives, and processes). It is the responsibility of top management to review the health of environmental management system!

The management review process

The following process diagram shows the inputs, the process, and resulting outputs of the management review process. Reviews must be conducted at planned intervals and records must be maintained.



Review outputs must result in decisions and actions for possible changes to the environmental policy, objectives and targets to continually improve the EMS. Management review is a significant indicator of management's commitment to the environmental management system.


Top management must periodically review the EMS.

Ensure top management defines the management review process. Part of that definition must include how often management reviews will be held. Be careful here because management reviews must be held at planned intervals. That means that you must define what those intervals are. You may say you hold the management reviews annually, twice a year or even quarterly. The critical thing is that you ACTUALLY hold management reviews when you say you will. If you do not this will be an audit nonconformance. Decide who will chair this meeting and who will attend. It may be chaired by the management representative but since this is management’s opportunity to learn about the health of the EMS, management is expected to attend as well as those individuals who are most qualified to report on the different inputs to management review. For example, you might expect to have the audit manager present to report on the results of audits. It is a good idea to retain an attendee list and have the attendees sign next to their name as objective evidence of their attendance.

Ensure the management review addresses audits, communications from external parties and environmental performance There are certain things that you MUST discuss during management review and your meeting minutes MUST reflect this discussion. If you have an agenda ensure that for every item on the agenda you have the corresponding discussion documented in the meeting minutes. Remember when you are audited, if it isn’t in the meeting minutes, YOU DID NOT discuss it. Ensure the following discussions are reflected in your meeting minutes:

• Results of internal audits and compliance evaluations. Your meeting minutes should reflect a discussion of the results of the internal audits and the compliance evaluations. Include the number of audits scheduled and how many were completed. Speak to the results of these audits and include any major concerns. Hold the same discussion with compliance evaluations.

• Communications from external interested parities. Discuss any contacts the organization may have had from neighbors, newspapers, shareholders or anyone else



external to the organization, what they had to say and how you responded. Remember that form you developed for recording external communications (4.4.3)? This is where the information for this discussion should come from.

• Environmental performance of the organization. How is the organization doing towards becoming more environmentally friendly?

Ensure the management review addresses objectives and targets, corrective and preventive actions, and action items

• Meeting minutes must reflect discussions regarding progress towards objectives and targets. Are we meeting our targets? If so, how will we set the bar higher? If not, what are we doing to correct the situation? This would be a good place to include charts and graphs showing trends.

• Include discussions regarding the status of corrective and preventive actions. How many CARs/PARs were issued, how many are still open and how many have we closed? For open CARs/PARs discuss why they are still open. Are we having problems getting them addressed? If so, this is your opportunity to let management know and hopefully take action. During an audit, you will get a nonconformance if your CARs/PARs are not addressed in a reasonable amount of time.

• Your minutes should include a discussion of action items from previous management reviews. During each management review develop an action item list. This list should be based on the discussions during the management review. For each action item assign responsibility for its completion. During the next management review have that person discuss progress towards that action item. If it has been completed then close the item. An auditor should be able to see the trail of action items generated during one management review, reviewed during the next management, and new items generated during that management review, etc

Interpretation guidance This ends the clause-by-clause review of ISO 14001-2004. Remember, when questions of interpretation come up, consult the standard first. The best overall interpretation guideline is that common sense should prevail because the standard was written to create value for the users.

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