Internal Auditor Training

For Environmental Management Systems

EMS Implementation Workshop

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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

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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

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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
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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
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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
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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
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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

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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
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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
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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”
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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
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ISO 14000 Series and ISO 14001

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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)
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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
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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.

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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.
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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

• • •

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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)
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Organizational Evaluation Standards
* EMS * Auditing * Environmental Performance Evaluation PRODUCT EVALUATION STANDARDS * Life Cycle Assessment * Labeling * Environmental Aspects in Product Design
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An Overview of Environmental Management Systems (EMS) and the ISO Standard

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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.”

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

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

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

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

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

Determine Legal and Other Requirements

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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.
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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
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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
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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
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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
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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
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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
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Implementation and Operation
Organization & Accountability Capabilities & Communications Controls

Document Control Training, Awareness and Competence Structure and Responsibility Communication Emergency Preparedness and Response
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Operational Control

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.

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

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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
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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

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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
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Checking and Corrective Action
Monitoring and Measuring Non-conformance, Corrective and Preventive Action Records

Periodic Internal EMS Audits

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4.5 Checking and Corrective Action
4.5.1 Procedures for Monitoring and Measurement operations and activities related to environmental aspects. Procedures to address Non-Conformance and Corrective and Preventive Action. Procedures for identification, maintenance, and disposition of Environmental Records. Procedure for periodic Environmental Management System Audit.
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4.5.2

4.5.3

4.5.4

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

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Monitoring and Measurement
• Established and maintain a documented procedure to periodically assess compliance with environmental regulations

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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 nonconformance
– – – – Mitigate impacts Identify cause Develop corrective action and implement it Modify procedures if necessary to prevent recurrence
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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
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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
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Management Review
Take account of: • audit findings • progress records on objectives changes to facilities • changes in activities, products or services • changes in technology • concerns of interested parties • other relevant information To Assess the • suitability, • adequacy, and • effectiveness of the EMS

In order to determine the need for change and improvement to: • the environmental policy • the objectives and targets • other elements of the EMS

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

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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!
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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
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EMS Implementation Workshop

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.
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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.

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

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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
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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)
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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
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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

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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
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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
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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
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Audit Definitions

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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

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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

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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.
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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.
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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.
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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.

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Conducting the Audit

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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.)

Continual Improvement
Mechanisms in place to improve (including fixing non-conformances and improving performance)
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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
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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?
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Audit Process Planning the Audit

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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
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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!
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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
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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
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Audit Process Opening Meeting

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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 EMS 91 stage of the auditImplementation Workshop

Audit Process Conducting Interviews

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

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Typical Questions of any Employee:
1. 2. 3. 4. 5. 6. 7. What does the EMS policy say and what does it mean to you? What is your familiarity with the EMS program? What do you do in case of a procedural nonconformance? What do you do in case of a emergency? What kind of training have you received? How do you communicate environmental concerns or ideas? What do you do if you receive environmentallyrelated communication from external parties?
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Typical Questions of Critical Operations (Con’t):
1. your What are the significant aspects and impacts associated with function? How do you know what to do? (Ask for procedures and operating criteria). What specific training have you received? What are the objectives and targets associated with your function? What is your responsibility for monitoring and measurement activities? What records do you keep? (Any other specific questions prompted by answers 1-6 and/or specific circumstances?)
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2. 3. 4. 5. 6. 7.

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
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Audit Process
Examining Documents and Records

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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”
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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?

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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”)
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Documentation Structure
LEVEL I – POLICY MANUAL Briefly describes how organization acknowledges required elements of the standard and points to next level detailed procedures.
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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
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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.
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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.
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Procedure
In order to identify the environmental aspects activities, products and services, the following procedures can be followed: 6. 7. 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. 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. 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. 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. 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. Upon new processes or changes, modifications will be evaluated for changes to the aspects lists.

8.

9. 10.

11.

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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.
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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.

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Aspects Procedures • Aspects list • Significant determination information • Significant aspects/impacts list

Typical Documents and Records to Review (by Element)

Legal and Other Requirements • Listings of applicable legal and other requirements • Appropriate instructions for compliance • Permits, manifests, etc.
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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
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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
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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
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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
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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
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Management Review Meeting agendas and attendance Meeting minutes and action items Evidence of follow-up actions, reports, etc.

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Audit Process Determining Findings

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Non-Conformances
Determining Type and Severity Writing up Non-Conformances

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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.

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Types of EMS Nonconformance
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.
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Types of EMS Nonconformance
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.

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Non-Conformances vs. NonCompliances
• 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 noncompliances but no EMS nonconformances, and vice versa.
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Audit Process Audit Reporting

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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
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# 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

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– 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.
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Audit Process Closing Meeting

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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

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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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