Auditor Training 8.22.03

Internal Auditor Training
For Environmental Management Systems
EMS Implementation Workshop 1

Course Overview and
Objectives
• To learn principles and practices of EMS
auditing, using ISO 14001 as the basis
• Will use class lecture, discussion,
assignments, and exercises
• Modeled after the five day lead assessor
class

Agenda Day One
• Introductions and Logistics
• Course Objectives and Overview
• EMS Drivers and Roadblocks in Government
• Current Status of EMS Efforts
• ISO 14000 Series Overview
• ISO Standards Process
• ISO 14001 Element Requirements

Agenda Day Two
• ISO 14001 Element Requirements (continued)
• Internal, External, First, Second, and Third Party Audits
• Certification, Self Declaration Processes
• ISO 19011, Guide 66, and related guidance documents
• Key Legal and Other Requirements (Regulatory, Executive Orders, and
Others)
• Audit Types: EMS vs. Compliance
• EMS Scope and Audit Scope
• Audit Principles and Definitions
• Elements of an EMS Audit Program
• Auditing Process: Planning (Objectives)
• Role of the EMS Auditor

Agenda Day Three and Four
• Auditing Process: Team Selection
• Auditing Process: Activities Planning
• Auditing Process: Conducting the Interviews
• EXERCISE (Practicing Questions)
• Auditing Process: Examining Evidence
• EXERCISE (Reviewing EMS documents)
• Auditing Process: Generating Findings
• Types of Non-conformances
• EXERCISE (Writing Findings and Non-conformances)
• Auditing Process: closing Meeting
• Auditing Process: Audit Reporting
• Auditing Process: Audit Follow Up
• Day Four (AM Only)- EXAM

EMS Implementation Workshop
EMS Drivers and Roadblocks

in the Federal Government
The Drivers - Why EMS?
History/perspective
• EMS responded to “root causes” for poor
environmental program management and
compliance problems
• EMS has corollary benefits of management
systems to mission and environmental
stewardship
• EMS represents the next step in evolution
from compliance, to pollution prevention
(for compliance), to EMS
EO 13148
• Establishes EMS as environmental
management policy for the Federal
government
• Requires agencies to incorporate EMS into
agency environmental directives and
policies
• Requires facilities to develop and
implement EMS by December 31, 2005

Benefits of an EMS
• Improved environmental awareness,
involvement and competency across
organization
• Better communication of environmental
issues - internal and external
• Positive effect on regulatory compliance
and environmental performance

Benefits of an EMS
• Improved efficiency, reduced costs, greater
consistency in environmental program
• Flexibility and opportunity to correct
imperfections through “continual
improvement”
• Identification of risk and prevention of
problems outside of regulatory - e.g., aging
infrastructure, known unregulated hazards

Barriers - What stands in the
way of EMS?
• Organizational change - natural resistance
to change in any organization
• Lack of top management involvement and
visibility
• Organizational issues - “that’s an
environmental responsibility”
• “That’s my responsibility” from the
environmental shop
Potential Barriers
• small p and BIG P political uncertainty - is
EMS here to stay?
• Perception that EMS already exists -
systems exist now, why change?
• Misunderstanding of relationship to mission
“environment only gets in the way of
mission”

Current Status of EMS in the
Federal Sector
• Much activity in federal government related to EMS
efforts.
• Many using ISO 14001 directly, or as the foundation for
their EMS.
• Some sites getting certified.
• To date, 200+ sites with EMS, 20 certified. Many more
underway.
• Outreach and training being done and more on the way.
• Tools and case studies available and more being created.
• Self declaration protocol issued in September 2003

ISO 14000 Series and
ISO 14001

EMS and ISO 14001
• 14001 is one of the standards in the 14000
series
• Created by International Organization for
Standardization (Geneva, Switzerland)
• Each participating nation has a committee
that develops consensus and contributes
(one vote each, for US it is ANSI)

EMS and ISO 14001
• USTAG to TC207
• Finalized and issued in 1996, revised every
five years
• Market sector created and driven;
governments participate but it is not
legislative or regulatory
• Process standard, not performance

ISO 14001 Application
• Extent of application of ISO 14000 will depend on organization’s :
- Environmental policy;
- Nature of its activities; and
- Conditions under which it operates.
• ISO 14000 is applicable to organizations that wish to:

- Implement and maintain an environmental management system;
- Assure conformance with stated environmental policy;
- Demonstrate such conformance to others;
- Seek certification of its environmental management system;
- Make a self-determination and declaration of conformance with
the standards; and/or
- Improve operating performance.

More Definitions ….
• SPECIFICATION STANDARD: That portion of the
standards against which you are independently audited and
certified. Uses the word “SHALL”.
• GUIDANCE STANDARD: A standard, but not a
requirement for certification. Used to help implement the
specification document. Uses the words “SHOULD” or
“MAY”.
• GUIDANCE DOCUMENTS AND ANNEXES:
Additional documents associated with either the
specification or guidance standards which provide
additional explanation or assistance.

What Standards Compose the Series?
• ISO 14001
- Environmental Management Systems.
- Specification with guidance for use.
• ISO 14004
- Environmental Management Systems.
- General guidelines on principles, systems, and supporting techniques.
• ISO 14010 (Canceled)
- Guidelines on Management Systems Auditing (General Principles)
• ISO 14011-1 (Canceled)
- Guidelines for Environmental Auditing (Audit Procedures)
• ISO 14012 (Canceled)
- Guidelines for Environmental Auditing (Qualification criteria for
Environmental Auditors)
• ISO19011 replaces 14010, 14011, 14012

What Standards Compose the Series?
• Due Diligence and Site Assessments (ISO 14015)
• Environmental Labeling and Declarations (ISO
14020-series)
• Environmental Performance Evaluation (ISO
14031)
• Life Cycle Assessment (ISO 14040-series)
• Environmental Aspects In Product Design
(ISO/TR 14062)
• Environmental Communication (ISO 14063, under
development)
• Climate Change (ISO 14064, under development)
Organizational Evaluation
Standards
* EMS
* Auditing
* Environmental Performance Evaluation
PRODUCT EVALUATION STANDARDS

* Life Cycle Assessment
* Labeling
* Environmental Aspects in Product Design
An Overview of Environmental
Management Systems (EMS)
and the ISO Standard

WHAT IS AN ENVIRONMENTAL
MANAGEMENT SYSTEM?
The ISO 14001 Definition
• “The overall management system that includes
organizational structure, planning activities,
responsibilities, practices, procedures, processes
and resources for developing, implementing,
achieving, reviewing and maintaining the
environmental policy.”

“ems” vs. “EMS”
• One can state they have some type of
environmental management system; regardless of
what they do
• For this discussion, EMS is the more formalized,
recognized, and structured approach of adopting
and implementing an accepted EMS framework
such as ISO 14001
• In most cases, additional effort is needed to
transition from current environmental programs to
the more formal EMS

What an EMS is
• A formal, structured framework of policies,
procedures and practices to manage and reduce an
organization’s environmental footprint
• Based on a PLAN-DO-CHECK-ACT framework
• An approach that reflects the relationship between

environmental issues and core mission
What an EMS is NOT
• A one-time project, plan or initiative
• Focused solely on regulatory compliance
• An effort solely for the environmental shop

An Effective EMS is:
Flexible
Transparent
Useful to the “practitioner”
In harmony with mission focus
Focused on continual improvement

Important EMS Terms
• “Shall”
• “Establish and Maintain”
• “Responsibility and Authority”

Plan Do Check Act
Continual Improvement
Management Environmental
Review Policy
Checking & Corrective Planning

Action
Implementation &
Control

Policy
• Top management is responsible!
• Statement of an organization’s intentions
and principals in relation to its overall
environmental performance
• Provides a framework for the EMS
objectives and targets
• Is documented, communicated and
implemented
Policy
• Reflects nature and scale of organization
• Includes commitment to continual
improvement and pollution prevention
• Includes commitment to compliance with
regulatory and other requirements
• Communicated internally and externally

Planning
Identif Determine
Environmental
y Significant Develop
Aspects and Environmental Establish
Identify
Impacts Aspects Environmental
Activities, Objectives
Products and Management
and Targets
Service Determine Legal and Other Program
s Requirements

4.3 Planning
Establish, Maintain, and Document:
4.3.1 Procedure to identify Environmental Aspects.
4.3.2 Procedure to identify legal and other
requirements.
4.3.3 Environmental objectives and targets.
4.3.4 Program for achieving objectives and targets,
including responsible individuals and time
frames.

Environmental Aspects
• Establish and maintain a procedure to identify
environmental aspects of activities products and
services that you “can control and over which you
can be expected to have an influence”
• To determine those which have or can have
significant impacts on the environment
• Examples include air emissions, water discharges,
soil contamination, use of raw materials, energy
use, use of natural resources
Acti vi ti es, Products
and
Servi ces
• This is what you do at your facility – mostly
“activities” for Feds
– Mission – what ‘facility’ is designed to do -
e.g. visitor center
– Activities that support the mission – e.g.
vehicle maintenance
– Actions that are both regulated and not
regulated e.g. commuting to work

Dete rm in in g
Sig nific ant Asp ects
• Determined by YOU! What is important in
your situation.
– Considers likelihood, severity, frequency,
duration, boundaries, stakeholder concerns
– Reflects normal, unique, and emergency
conditions
• Significance is based on environmental
impact
Legal a nd Other
Re quir eme nts
• Establish and maintain a procedure to
identify legal requirements that apply to
your facility’s aspects – use audit guides or
protocols
• Identify other requirements to which you
“subscribe” e.g., Executive Orders,
agency/bureau policies or voluntary
practices
Ob jective s a nd
Ta rgets
• Establish and maintain documented environmental
objectives and targets
• Consider “legal and other requirements”
• Consider significant aspects
• Reflect financial and technical limitations
• Reflect “interested parties”
• Reflect policy commitment and commitment to
pollution prevention
• Results guide how you will measure progress
En viro nme ntal
Ma nagement Pro gram
• Establish and maintain a program to achieve
objective and targets
• Assign responsibility
– Function
– Level
• Describe what is to be done, what will be
measured, and what the time frame will be

Implementation and Operation
Organization & Capabilities & Controls
Accountability Communications
Document Control
Training,
Awareness and
Competence
Operational Control
Structure and
Responsibility
Communication
Emergency
Preparedness and
Response
4.4 Implementation and
Operation
4.4.1 Structure and responsibility of system and
persons involved with maintaining the EMS
includes identifying Management Representative.
4.4.2 Identification of training needs, and procedures for
training, awareness and competence.
4.4.3 Procedures for communications.

4.4 Implementation and
Operation (cont.)
4.4.4 EMS documentation.
4.4.5 Procedures for Document Control.
4.4.6 Operational Control – identification
and control of procedures associated with policy,
aspects, objectives and targets.
4.4.7 Procedures related with Emergency
Preparedness Response.

St ructure a nd
Re sp onsi bility
• Roles and responsibilities are defined,
documented, communicated
• Management provides resources for
implementation of the system
• Management identifies Management
Representative that is responsible for and has
authority for
– Managing EMS implementation
– Reporting to top management on EMS progress

Tr aining Awa reness
and Co mpetence
• Establish and maintain a procedure for
training relevant to
– EMS - awareness including policy
– Relationship between employee activities and
environmental impacts
• Ensure competence training to
– Regulatory requirements
– Standard operating procedures

Co mmu nicatio n
• Establish and maintain a procedure
– For internal communication – between levels
and functions BOTH WAYS!
– For addressing external communications

Do cument Co ntrol
• Establish and maintain procedures for
controlling system documents
– Can be located - are legible, dated and
maintained
– Reviewed and revised as necessary and
approved
– Current versions are available to practitioner
– Obsolete documents are removed from use and
maintained if necessary
Op eratio nal Co ntr ol
• Identify operations and activities associated with
significant environmental aspects
• Establish and maintain procedures for addressing
activities that affect significant aspects to avoid
deviations from policy and objectives and targets
• Considering goods and services, communicate
procedures to suppliers and contractors

Em ergency
Pr epare dness a nd
Re sp onse
• Establish and maintain procedures to
– Identify potential for emergencies
– Address accidents and emergencies
– Prevent, respond to and mitigate environmental
impacts
– Review and revise procedures after emergency
or accident
– Test where appropriate
Checking and Corrective
Action
Non-conformance,
Monitoring and Corrective and
Measuring Preventive Action Records
Periodic Internal EMS Audits

4.5 Checking and Corrective
Action
4.5.1 Procedures for Monitoring and Measurement operations and
activities related to environmental aspects.
4.5.2 Procedures to address Non-Conformance and Corrective and

Preventive Action.
4.5.3 Procedures for identification, maintenance, and disposition of

Environmental Records.
4.5.4 Procedure for periodic Environmental Management System

Audit.

Mo nitorin g a nd
Me asu reme nt
• Establish and maintain documented
procedures to monitor and measure
activities related to significant aspects
– Formally track performance, operational
control
– Reflect objectives and targets
– Maintain and calibrate monitoring equipment

Monitoring and Measurement
• Established and maintain a documented

procedure to periodically assess compliance
with environmental regulations

No n Co nfo rm ance,
Co rrective a nd
Pr eve ntive Ac tio n
• Establish and maintain procedures defining
responsibility and authority to address non-
conformance
– Mitigate impacts
– Identify cause
– Develop corrective action and implement it
– Modify procedures if necessary to prevent
recurrence
Re cords
• Establish and maintain procedures for
identification, maintenance and disposition
of environmental records
– Training
– Audits or other reviews
– Legible and traceable to the activity, product or
service involved
• Demonstrate conformance to Standard
Inte rnal EM S Au dits
• Establish and maintain a program and
procedures to periodically audit to
determine if the EMS,
1) is being properly implemented and maintained,
and
2) conforms to the standard
• Audit information provided to management

Management Review
To Assess the
• suitability,
Take account of: • adequacy, and
• audit findings • effectiveness of the EMS
• progress records on objectives
changes to facilities
• changes in activities,
products or services In order to determine the need
• changes in technology for change and improvement to:
• concerns of interested parties • the environmental policy
• other relevant information • the objectives and targets
• other elements of the EMS

Plan Do Check Act
Management Environmental
Review Policy
Checking & Corrective Planning

Action
Implementation &
Control

The Three C’s of an Effective
EMS
Conformance
Meets the requirements (Implements the “shalls”)
Consistency
Various elements inter-related (i.e., Significant aspects reflected
in emergency planning, etc.)
Continual improvement
Mechanisms are in place to improve the EMS and organizational
performance, supported by management commitment and
support
Keep in mind…
• The EMS and related measurement tools are just
that, tools. Alone, they will not guarantee success.
The organization must use the tools, not just have
them.
• An effective EMS is “alive”; constantly measuring
performance, making adjustments, and looking for
opportunities for continual improvement
• Accountability is critical

Keep in mind - AN EMS
• Is a management system -
– THAT’S WHAT MAKES IT WORK!!
• Is more than compliance - includes safety, energy,
water etc. and non-regulated impacts
• Supports mission!
• Takes time - it is a process, not an event
• Requires the environmental people to get out of
their box -
• EMS requires commitment - its not a part-time
job!
Summary
• A formal EMS reflects an accepted framework for
managing the environmental footprint of your
organization
• Most organizations already have several EMS
elements in place - the system relationship is
lacking and can be achieved by adopted a formal
framework
• Success comes from following the framework and
being committed to implementation

EMS Auditing
Environmental Management System
The part of the overall management system that

includes organizational structure, planning
activities, responsibilities, practices, procedure,
processes and resources for developing,
implementing, achieving, reviewing and
maintaining the environmental policy.

Environmental Management
System Audit
A systematic and documented verification process of

objectively obtaining and evaluating evidence to
determine whether an organization’s environmental
management system conforms to the environmental
management system audit criteria set by the organization,
and for communication of the results of this process to
management.

EMS Audit
• Not a compliance audit
• Done by those with EMS auditing
training/experience
• Periodic “snap-shot” assessment to verify
system

Internal vs. External Audits
• Internal audits (First Party audits) are those done
by participants of the EMS being audited (can be
employees, or consultants as agents of the
organization)
• Second party audits are those done by auditors
from outside the EMS in question (but could be
from same organization)
• Third party audits are done by independent,
registrars
• In all cases, audit should cover same
elements!!!! EMS Implementation Workshop 66
Certification vs. Self Declaration
• In both cases, a representation is made to outside
parties of conformance to EMS criteria.
• Certification is done by accredited, third party
registrars
• Self-Declaration is any other claim of
conformance other than certification
• Self-Declaration should be more than internal
EMS audit

EMS Auditing and ISO
• ISO created companion auditing guidance
standards (14010, 14011, 14012 (soon to be
19011), but these are not required for certification
• Registrars must adhere to these at a minimum
• ISO issues guidance to certification and
accreditation bodies (Guides 66, IAF Guidance,
ISO 17021) (can be used to guide self declaration
programs)
• US accrediting body is ANSI-RAB (Etheridge
Series of documents)
ISO 19011
• Guidelines for Quality and/or
Environmental Management Systems
Auditing
• Finalized in 2003; adopted by ANSI for
United States with supplemental guidance
• ISO 19011 cancels ISO 10011 (QMS) and
14010, 14011, 14012
• ISO 19011 is basis for this course
Key Legal and Other
Requirements
• All media regulations (RCRA, CWA, CAA,
etc)
• Executive Orders (13148, 13101, 13327,
etc)
• Agency and sub-agency level requirements
• Voluntary programs

Self Declaration and EO 13148
• Protocol developed by EO Workgroup
• EMS verification procedures will rest with
each Agency/Bureau
– Procedures due by December 31, 2004
– Updated at least every five years
• Procedures will require an independent
basis
• Facilities may self declare prior to
procedures using protocol guidance
Agency Self Declaration
Procedures
• Will include
– Selection and direction for use of evaluation
guide
– Frequency of internal evaluations
– Requirement for management declaration
– Frequency of independent review
– Makeup of review team including qualifications
of independent reviewers
EMS vs. Compliance vs. EMR
Auditing
• Different criteria- EMS looks at system,
compliance looks at regulatory
requirements
• EMS audit is a system, or process audit, a
compliance audit looks at compliance
performance (compliance status), EMR
looks at pieces of the system or a very
broad perspective
Audit Definitions

Audit Scope
• The audit scope defines what the audit will
cover; and usually means the same as the
scope of the EMS
• If audit is done in parts; the scope of any
one specific audit may be a subset of the
entire EMS

Audit Objective
• The audit objective(s) is why the audit is
being conducted
• Typically, the main objective is to verify
conformance to the standard and the EMS
planned arrangements

Audit Criteria
Policies, practices, procedures or requirements against
which the auditor compares collected audit evidence
about the subject matter.
NOTE: Requirements may include but are not limited

to standards, guidelines, specified organizational
requirements, and legislative or regulatory
requirements.

Audit Evidence
Verifiable information, records or statements of
fact.
NOTES:
Audit evidence, which can be qualitative or quantitative, is used by the
auditor to determine whether audit criteria are met.
Audit evidence is typically based on interviews, examination of documents,

observation of activities and conditions, existing results of measurements
and tests or other means within the scope of the audit.

Audit Findings
Results of the evaluation of the collected

audit evidence compared with the agreed
audit criteria.
NOTE: The audit findings provide the

basis for the audit report.
Audit Conclusion
Professional judgement or opinion expressed

by an auditor about the subject matter of the
audit, based on and limited to reasoning the
auditor has applied to audit findings.

Conducting the Audit

The Three C’s of Auditing EMS
Conformance
Meets the requirements
(implements the “shalls”)
Consistency
Various elements inter-related
(I.e., significant aspects reflected in emergency planning, etc.)
Mechanisms in place to improve
(including fixing non-conformances and improving performance)

Basic Rules of Auditing
• Be objective- i.e., do not keep an audit
going until you find a problem
• Be fair and consistent
• Stay focused on the criteria
• Stay within the scope and plan
• Do not start developing findings at the same
time you are collecting evidence
Specific Evidence to Look For
• Consistency of identified aspects and observed
aspects
• How activities match procedures
• Employee awareness of relevant EMS
elements
• Addressing non-conformances through the
non-conformance process
• Is the system effective and adequate?
• Is top management committed to the EMS?
Audit Process
Planning the Audit

Audit Planning
• Addresses the specifics of who, what,
where, when, and how
• Identifies auditors
• Identifies when the audit(s) will occur
• Identifies what format, checklists, etc will
be used
• Establishes specific agendas
• Must align with site procedure for auditing
Audit Approach
• Can do either all at one time, or divided up
throughout the year.
• If divided, must decide on whether to do
one element of the standard across the plant,
or
• All elements in pats of the plant
• Keep in mind consistency issue!

Audit Approach (cont.)
• Audits typically include:
– Interviews
– Site Reconnaissance
– Records review
• In any type of audit, the auditor will
compare evidence to criteria, and develop
findings

The Audit Team
• Must collectively have knowledge of:
– EMS
– Auditing
– Process or activities
– Environmental legal and other requirements
– Environmental Science
– Any unique, site-specific needs

Audit Process
Opening Meeting

Topics for Opening Meeting
• The overall duration of the proposed audit
• The starting location and time
• The proposed scope and areas to be covered
by the audit
• A timetable for approximate progress of the
audit where applicable, e.g., if a number of
different departments or geographical areas
are to be included in the scope of the audit
• The arrangements for any close out meeting
where the findings of the audit can be agreed
and corrective action requirements discussed
• The personnel liable to be involved at each
stage of the audit
Audit Process
Conducting Interviews

How to Interview
• Attitude of the auditor
• Purpose of the interview
• Types of questions; open, closed, leading,
antagonistic, vague

Typical Questions of any Employee:
1. What does the EMS policy say and what does it mean
to you?
2. What is your familiarity with the EMS program?
3. What do you do in case of a procedural
nonconformance?
4. What do you do in case of a emergency?
5. What kind of training have you received?
6. How do you communicate environmental concerns or
ideas?
7. What do you do if you receive environmentally-
related communication from external parties?
Typical Questions of Critical
Operations (Con’t):
1. What are the significant aspects and impacts associated with
your
function?
2. How do you know what to do?
(Ask for procedures and operating criteria).
3. What specific training have you received?
4. What are the objectives and targets associated with your
function?
5. What is your responsibility for monitoring and measurement
activities?
6. What records do you keep?
7. (Any other specific questions prompted by answers 1-6 and/or
specific circumstances?)
Types of Interviewees:
Plant management
Management representatives
Department managers
Document control and record departments
Research and development
Engineering
Operations employees (plant, administration)
Human resources and training
Contractor management and purchasing
Security
Audit Process
Examining Documents and Records

Documentation
• Say what you do
• Do what you say
• “Record” it (paper or electronic)
Must be:
– relevant to EMS (link to aspects)
– Usable and appropriate
– Controlled
– Reviewed and revised as “continual improvement”

What Auditors Look for in Terms of
Documentation
• Does your documented system respond to the

standard?
• Do the procedures describe what’s happening?
• Is the documentation controlled?
• Are all employees informed?
• Are the procedures followed, by everyone, all the time?
• Is there objective evidence that the procedures are
being followed?

Documentation Hierarchy
Level I = Upper Level “Road Map”

Level II = System Procedures
Level III = Work Instructions
Reference documents = Regulations, etc.
Records - Verify the system (not
“controlled”)

Documentation Structure
LEVEL I – POLICY MANUAL
Briefly describes how organization

acknowledges required elements of the
standard and points to next level detailed
procedures.
Example of Level I Entry
Planning
1. Environmental Aspects
Documented procedures are maintained to identify the environmental aspects of the

organization’s activities and products that it can control and over which it can be
expected to have an influence. These aspects are identified in order to determine those
which have, or can have, significant impacts on the environment. Those aspects related
to significant impacts are considered in setting the organization’s environmental objects.
The procedure is the responsibility of the Environmental Manager and includes update
provisions to ensure that the information concerning environmental aspects is kept up to
date.
References: Identification of Environmental Aspects and Impacts
Setting Objectives and Targets

LEVEL II – Management System
Procedures
Relatively short (1 to 3 pages) procedures,

usually ISO 14001 element-specific, and
describes how the EMS manages each
requirement.

Example of Level II Entry
LEVEL II PROCEDURE
BACKGROUND ENVIRONMENTAL ASPECTS ANALYSIS
As required by ISO 14001, environmental aspects and impacts must be identified in order to
develop an appropriate EMS.
The aspects analysis is intended to be a general data gathering effort to establish the
environmental character of the site as opposed to a comprehensive audit or assessment.
The purpose of the aspects analysis is to determine how the activities, products and
services of the facility interact with the environment. Ultimately, the methodology will
get documented so that the future aspects of the facility’s operations can be identified
and reviewed in a consistent manner on an ongoing basis.
An environmental aspect is any element of the organization’s activities, products and
services which can interact with the environment that it can control and over which it
can be expected to have an influence. The impact is the change which occurs in the
environment, positive or negative. Existing as well as potential aspects and impacts are
identified.

Procedure
In order to identify the environmental aspects activities, products and services, the following procedures can be
followed:
6. Review the site operations in order to prepare a list of categories that the activities, products and services can be placed
into. These categories may include chemical storage, wastewater treatment and product transportation among others.
7. Conduct interviews with appropriate personnel and conduct a reconnaissance of the site to identify the various
operation units of the facility which interact with the environment. Migration and transport pathways and
environmental receptors will be noted in order to document how the activity, product or services were identified as
relevant.
8. Review documented corporate environmental policies and related documents such as performance standards,
procedures and compliance management tools to assist in determining the environmental character of the facility. This
information will also be used in ultimately determining the significance of the impacts of the aspects.
9. Assess the impacts from the aspects. The impact assessment should evaluate the aspects under both normal and
abnormal operating conditions, and for actual and potential conditions.
10. Determine the criteria for determining the significance of the identified aspects. Examples of such criteria would be
issues that result in public complaints, incidents that involve the release of a substance which is immediately harmful to
health and the environment, and/or releases that exceed regulatory requirements. The definition of significance is
determined by the site management. Significant aspects are then noted accordingly, and used to guide development of
objectives, targets, and implementation of the EMS.
11. Upon new processes or changes, modifications will be evaluated for changes to the aspects lists.

Records
The data is then compiled into matrix form listing environmental aspects and impacts. The
listing is divided by site activities, products, and services. Within each such division, the list
is further subdivided by aspect category, including air, water, and solid wastes, energy,
resource consumption, and human and ecosystem impact. This listing, and related
subsequent modifications and versions, are considered records of the EMS, and can be used
to review and verify the Aspects Determination procedure. From this list, the organization
will then select and list those aspects to be considered significant (see Step 5 on previous slide).
Aspects and Impacts are generalized in the listing. More details can be input, as appropriate,
depending on the ultimate use of the information. For example, impacts can be listed as
“regulatory requirements”, but specific permit needs may not be itemized in the listing for a
given aspect.
Responsibility
The aspects analysis is the responsibility of the Environmental Manager and the Aspects
Team.

LEVEL III - WORK INSTRUCTIONS
Functional instructions and specific how-to procedures. Typical SOP’s, e.g.,

audit protocols, equipment operation, waste disposal, etc.
REFERENCE DOCUMENTS
Supporting documents outside the EMS procedures, e.g., regulations, permits.
RECORDS
Verification documentation resulting from procedures, e.g., audit reports,

annual reports, meeting minutes.

Typical Documents and
Records to Review (by
Element)
Aspects Procedures
• Aspects list
• Significant determination information
• Significant aspects/impacts list
Legal and Other Requirements

• Listings of applicable legal and other requirements
• Appropriate instructions for compliance
• Permits, manifests, etc.
Objectives and Targets and Environmental Management
Programs
Minutes/notes of objectives and target development

List of objectives and targets
Related action plans
Structure and Responsibility
Job descriptions
Organizational charts

Training Awareness and Competence
• Training needs listings/matrix

• Manuals, course materials
• Sign-in sheets
• Test records, certificate copies, etc.
Communication
• Specific work instructions

• Records of communication and correspondence

Document Control
* Documents, procedures, and manuals
Operational Control
* Critical operations/aspects listing/matrix

* Specific work instructions
* Environmental issues and instructions within other work
instructions
* Contractor policies, work orders, etc.
* Supplier requirements

Emergency Preparedness and Response
• Emergency plans and protocols

• Practice and drill results
Monitoring and Measurement
• Objectives and target action plans

• Specific procedures and work instructions
• Records of monitoring and measurement data
collected
Nonconformance, Corrective and Preventive Action
• Corrective actions reports
• Evidence of discussion and follow-up (meeting notes, etc.)
Records
• Records
EMS Audit
• Specific audit procedures, checklists, forms
• EMS audit notes and working documents
• EMS audit reports

Management Review
Meeting agendas and attendance
Meeting minutes and action items
Evidence of follow-up actions, reports, etc.

Audit Process
Determining Findings

Non-Conformances
Determining Type and Severity

Writing up Non-Conformances

Types of EMS Nonconformance
MAJOR
(results in system not meeting standard requirements, could hold certification)
Management Review
A review of the EMS is stated to be conducted on an annual basis. The review is to be

performed by the Management Representative. Review criteria includes data from
monitoring and measurement activities, corrective and preventive action, EMS audits,
and “other input”. Following the review an action plan is to be developed that defines
courses of action, responsibilities, and timeframes for completion.
The following major deficiency was noted:
–No records of management review are available.

Minor- (should be corrected by next audit cycle, could jeopardize
certification in future)
Environmental Management System Audit
Audit procedures have been developed and an EMS audit has been conducted.
The audit scope covered all areas of the facility against all criteria of the
standard. Auditors have received appropriate training. An audit report was
generated following the audit that outlined findings uncovered. Corrective
actions to audit findings appear to be addressed.
Several deficiencies were noted:
• Audit procedures are not detailed enough to demonstrate how the audit was
conducted (what records were reviewed, personnel interviewed, departments
visited).
• Audit records do not show which auditor reviewed which area, so that
independence of auditors can be shown.

Observation (suggested, optional improvement, no risk to
certification)
Communication
The applicable section of the EMS Manual describes procedures for
communications. The procedure describes how internal
communications are performed as well as the handling of external
communications received, including those by phone. The procedure
indicates that the site will document its decision on external
communication of its significant environmental aspects.

Non-Conformances vs. Non-
Compliances
• A system non-conformance is a situation
where the EMS is not doing what it should
be doing (may or may not be reflected in
performance)
• A system may have regulatory non-
compliances but no EMS non-
conformances, and vice versa.

Audit Process
Audit Reporting

The Audit Report
The audit findings and/or a summary thereof should be
communicated to the client in a written report. Unless
specifically excluded by the client, the auditee should
receive a copy of the audit report.
Audit-related information that may be in audit reports,

includes, but is not limited to:
• The identification of the organization audited and of the
client
• The agreed objectives and scope of the audit
• The agreed criteria against which the audit was conducted
✗ The period covered by the audit and the date(s) the audit
was conducted
✗ The identification of the auditee’s representatives
participating in the audit
✗ The identification of the audit team members
✗ A statement of the confidential nature of the contents
✗ The distribution list for the audit report
✗ A summary of the audit process including any obstacles
encountered
✗ Audit conclusions such as:
– EMS conformance to the EMS audit criteria

– Whether the system is properly implemented and
maintained
– Whether the internal management review process is
able to ensure the continuing suitability and
effectiveness of the EMS
• Distribute the report. The audit report should be sent to

the client by the lead auditor. Distribution of the audit
report should be determined by the client in accordance
with the audit plan. The auditee should receive a copy
of the audit report unless specifically excluded by the
client.
• Document retention.

Audit Process
Closing Meeting

Topics for Closing Meeting
• Acknowledgment of support
• Recap of audit scope, objectives, and plan
• Overview of findings
• Any special issues or circumstances
• Initial discussion of next visit

The Next Steps
Role of EMS Auditors in Corrective Action
• EMS auditors not required to provide assistance in
corrective action unless requested
• Should do so only if qualified; in other words
ability to audit does not equate with ability to fix
the problems
• EMS auditors must follow up on corrective
actions in subsequent audits
• EMS Auditors must look for continual
improvement

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Auditor Training 8.22.03

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Internal Auditor Training

For Environmental Management Systems

EMS Implementation Workshop 1

EMS Implementation Workshop 2

EMS Implementation Workshop 3

EMS Implementation Workshop 4

EMS Implementation Workshop 5

EMS Drivers and Roadblocks

EMS Implementation Workshop 8

EMS Implementation Workshop 9

EMS Implementation Workshop 10

EMS Implementation Workshop 12

EMS Implementation Workshop 13

EMS Implementation Workshop 14

EMS Implementation Workshop 15

EMS Implementation Workshop 16

• ISO 14000 is applicable to organizations that wish to:

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EMS Implementation Workshop 18

EMS Implementation Workshop 19

PRODUCT EVALUATION STANDARDS

EMS Implementation Workshop 22

EMS Implementation Workshop 23

EMS Implementation Workshop 24

• Based on a PLAN-DO-CHECK-ACT framework

• An approach that reflects the relationship between

• Focused solely on regulatory compliance

• An effort solely for the environmental shop

EMS Implementation Workshop 26

EMS Implementation Workshop 27

• “Establish and Maintain”

• “Responsibility and Authority”

EMS Implementation Workshop 28

Checking & Corrective Planning

EMS Implementation Workshop 29

EMS Implementation Workshop 31

EMS Implementation Workshop 32

EMS Implementation Workshop 33

EMS Implementation Workshop 35

EMS Implementation Workshop 39

EMS Implementation Workshop 41

EMS Implementation Workshop 42

EMS Implementation Workshop 43

EMS Implementation Workshop 44

EMS Implementation Workshop 45

EMS Implementation Workshop 47

Periodic Internal EMS Audits

EMS Implementation Workshop 49

4.5.2 Procedures to address Non-Conformance and Corrective and

4.5.3 Procedures for identification, maintenance, and disposition of

4.5.4 Procedure for periodic Environmental Management System

EMS Implementation Workshop 50

EMS Implementation Workshop 51

• Established and maintain a documented

EMS Implementation Workshop 52

• Audit information provided to management

EMS Implementation Workshop 56

Checking & Corrective Planning

EMS Implementation Workshop 57

EMS Implementation Workshop 59

EMS Implementation Workshop 61

The part of the overall management system that

EMS Implementation Workshop 63