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 organizations 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

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 (but can be used to guide self declaration programs) US accrediting body is ANSI-RAB
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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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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 EMS Implementation Workshop

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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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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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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AUDITING TOOLS AND TECHNIQUES

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The Three Cs 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

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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 19 EMS Implementation Workshop

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 devevlop findings
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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? EMS Implementation Workshop to the EMS? 22 Is top management committed

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 (Cont):

1.
2. 3. 4. 5.

6. 7.

What are the significant aspects and impacts associated with your 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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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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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 whats 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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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 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 auditees 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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Additional Information

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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.
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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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