1. finance
2. accounting and auditing

APPENDIX F
Phase IV Sample Documentation
SAMPLE DOCUMENTATION
Monitoring and Measuring
Sample Monitoring and Measuring Procedure – Charleston Public Works
Commission Year End Report – Charleston Public Works
F-2
SAMPLE DOCUMENTATION
CPW ENVIRONMENTAL MANAGEMENT SYSTEM
PROCEDURE
The on-line version and secured hardcopy are the controlled documents. The
secured hardcopy will be identified by an “Official Document” stamp giving date
of distribution. Any and all other documents are uncontrolled. Contact EMS
Program Manager for revision level status.
Effective Date:
Revision: 0
Title:
October 1, 2000
Page 1 of 2
Identification Number: EMS – 4.5.1 (A)
Monitoring and Measuring Key EMS Characteristics
Prepared By:
Reviewed By:
EMS Procedures Subcommittee
EMS Management Steering Committee
Approved By:
William E. Koopman, Jr., General Manager
John Cook PE, Assistant General Manager
August 25, 2000
Date Approved;
ISO 14001 1996-E, Sub Clause 4.5.1 Monitoring and Measuring
1.0 Purpose
This procedure describes the process for the scheduled monitoring and measurement of key characteristics
of the organization’s environmental management system activities.
2.0 Scope
This procedure addresses collection of environmental data associated with operations and activities that
have the potential to have a significant environmental impact.
3.0 Responsibility and Authority
3.1 The department head is responsible for submitting a monthly operating report (MOR) which
describes the key characteristics of the EMS and the status of the objectives and targets and
associated improvement programs.
3.2 The department supervisor(s) are responsible for generating environmental monitoring and
measurement data to be submitted in the Monthly Operating Report (MOR).
3.3 Executive management shall review the monthly operating reports to assure continuing suitability
and effectiveness of the EMS.
4.0 DEFINITIONS AND ACRONYMS
EMS
Environmental Management System
SAMPLE DOCUMENTATION
Effective Date:
Revision: 0
Title:
October 1, 2000
Page 2 of 2
Identification Number:
EMS
–
4.5.1
(A)
F-3
Monitoring and Measuring Key EMS Characteristics
F-3
Environmental Key Characteristics - an element of an operation or activity that
includes a measurement or an inspection process the results of which supports evaluation
of environmental performance of objectives and targets.
Monitoring - a systematic process of watching, checking, observing, inspecting, keeping
track of, regulating or otherwise controlling key parameters and characteristics of a
department’s management activities to determine conformance with a specific standard or
other performance requirement, or to measure progress toward its environmental
objectives and targets.
Measurement - a systematic method for estimating, testing, or otherwise evaluating key
parameters and characteristics of a department’s management activities to determine
conformance with a specific standard, other performance requirement.
5.0 Procedure
5.0.1
Monthly Operating Report (MOR)
A monthly report shall be established for department heads/supervisors to submit monitoring
and measuring information to support performance of the EMS. The report is to be structured
as a minimum to:
• Provide status of environmental management programs designed to fulfill environmental
objectives and targets,
• Provide status of performance indicators as related to targeted timeframes,
• Provide compliance status of environmental operating permits issued by environmental
regulatory agencies.
5.0.2 Performance Tracking
Environmental data collected to reflect environmental performance is to be maintained in such a
manner to allow the evaluation of progress toward realizing environmental objectives and targets.
6.0
Related Documents
Environmental Aspects,
Objectives, Targets, and Improvement Programs
Legal and Other Requirements
Operating Permits
7.0
RECORDS
Monthly Operating Report
F-4
SAMPLE DOCUMENTATION
Hanahan Water Treatment Plant
Environmental Management Systems
2000 Improvement Programs Year End Summary Report
F-5
SAMPLE DOCUMENTATION
Purpose: To provide a comprehensive report on environmental improvement programs implemented by the
Hanahan Water Treatment Plant Environmental Management Systems (EMS) Steering Committee to
promote environmental management and continual environmental improvements.
Scope: Programs included are those conducted during the 2000 calendar year. These programs include
specific significant aspects, related improvement plans and associated objectives and targets. Also included
are the results and observations associated with the success of each program.
Following are the improvement plan summaries within each aspect item:
Preventive/Predictive Maintenance:
Improvement Program HM.6003-Preventive Maintenance Program:
Objective HM.6003.2: Enter all existing equipment listed in the IMT Data File Folders and the respective
maintenance task instructions into CMMS database.
Target HM.6003.2: Complete entry of equipment listed in the IMT Data File Folders HI.3004.1.01 –
HI.3004.1.17 and the respective maintenance tasks into the CMMS database, and post in the ISO Controlled
Documents by April 30, 2000.
Target Met: April 2000
Results: As of April 28, 2000, the referenced target was met. Reported in the HWTP Monthly Report
HA.7002.M.Yr.
Observations: Effort to streamline EMS and maintenance records.
Improvement Program HM.6003-Preventive Maintenance Program:
Objective HM.6003.3: Enter all revised maintenance task instructions for existing and new equipment into
CMMS database.
Target HM.6003.3: Complete entry of all revised maintenance task instructions by June 30, 2000.
Target Met: May 2000
Results: As of May 2000, backlog draft task instructions (new and revised) and backlog draft datafile
folders (new and revised) from 11/15/99 to 5/15/00 and match equipment to CMMS database. Reported in
the HWTP Monthly Report HA.7002.M.Yr.
Observations: Effort to strengthen CMMS task instructions with maintenance activity details provided by
equipment suppliers/manufacturers. Subsequent task instruction revisions are prepared and entered into
CMMS on as needed basis.
Improvement Program HM.6003-Preventive Maintenance Program:
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SAMPLE DOCUMENTATION
Objective HM.6003.4: Through use of the CMMS/MP2, track preventive and corrective maintenance
manhours to increase maintenance efficiency.
Target HM.6003.4: Maintain performance level of 65% PM versus 35% CM (YTD average) for 2000
calendar year.
Target Met: December 2000
Results: 64.25% PM versus 35.75% CM; margin of error 1% due to unaccounted manhours. Reported in the
HWTP Monthly Report HA.7002.M.Yr.
Observations: Maintaining an average ratio of 65%PM versus a 35% CM helps reduce overall maintenance
costs and supports the company’s strategic plan. Margin of error calculated based on unaccounted for
maintenance manhours.
Improvement Program HM.6004-Valve PM & Inspection Program:
Objective HM.6004.2: Increase valve lifespan and reliability.
Target HM.6004.2: Identify and exercise 60 main valves by December 31, 2000
Target Met: June 2000
Results: As of June 2000, we have identified and exercised 70 valves. Reported in the HWTP Monthly
Report HA.7002.M.Yr.
Observations: We have exceeded the target for 2000 and continue to identify, locate, repair and exercise
plant valves. CMMS task instructions have been developed for valve PM and inspection. The valve program
has also identified critical main valves with special markers to allow rapid identification for emergency
procedures.
Improvement Program HM.6005-Predictive Maintenance Program:
Objective HM.6005.2: Complete vibration analysis software upgrade and data translation to Odyssey.
Complete chemical feed route.
Target HM.6005.2: Perform one vibration analysis on all identified equipment on chemical feed route by
April 30, 2000. Enter completed information into vibration analysis database and MP2 database by June 30,
2000.
Target Met: June 2000
Results: Completed one (1) vibration analysis on all identified equipment on chemical feed route. Software
upgraded to correct Y2K problem and to transfer data to SQL database. Reported in the HWTP Monthly
Report HA.7002.M.Yr.
Observations: None.
F-7
SAMPLE DOCUMENTATION
Improvement Program HM.6005-Predictive Maintenance Program:
Objective HM.6005.3: Schedule predictive maintenance using thermography technology on 25% of HWTP
prime moving motors (100 HP and above).
Target HM.6005.3: Schedule thermography scanning by April 30, 2000. Generate corrective workorders
from resultant report by May 15, 2000.
Target Met: May 2000
Results: Completed thermography scan on March 9, 2000. Generated one workorder as a result to correct
identified deficiencies. No capital expenditures required. Reported in the HWTP Monthly Report
HA.7002.M.Yr.
Observations: None.
Training:
Improvement Program HA.6006-Skills Based Training Program:
Objectives HA.6006.1: Increase basic skill level of Maintenance and I/E Associates
Target HA.6006.1: Through Technical Training Corporation (TTC) skills based training sessions and
testing, increase overall skills test average score for Maintenance & I/E Associates by January 31, 2000.
Compare scores to initial skills assessment.
Target Met: January 2000
Results: Table 1 identifies basic skills training topics to be covered by Technical Training Corporation for
1998 through January 2000. The date training was conducted is also included. Reported in the HWTP
Monthly Report HA.7002.M.Yr.
F-8
SAMPLE DOCUMENTATION
Table 1
Basic Skill Level Training
October 1998 – January 2000
Topic
Mechanical Training Plan
Shaft/Coupling Alignment
Bearing and Seals
Lubrication /Plan Development
Mechanical Drives
Blueprint Reading
Mechanical Principles
Benchwork
Torque/Fasteners
Pumps
Plumbing/Piping
Oxe Fuel Cutting
AC Arc Welding
Electrical Training Plan
Electrical Fundamental Review
Schematic Symbols
Power Distribution
Motors and Motor Controls/Control Devices
Electrical Devices
Transformers
Instrumentation
PLCs
National Electrical Code Requirements
Date(s) Training
Conducted
11/17/98, 11/18/98, 11/19/98, 11/25/98, 11/26/98, 11/27/98, 11/28/98,
12/01/98, 12/02/98, 12/03/98, 12/08/98, 12/09/98, 12/10/98, 12/15/98,
12/16/98, 12/17/98, 1/12/99, 1/13/99, 1/14/99, 1/19/99, 1/20/99, 1/21/99
8/19/99, 10/14/99
10/20/98, 10/21/98, 10/22/98, 11/11/99, 11/18/99
10/28/99, 11/4/99
6/17/99, 6/24/99, 7/15/99, 7/22/99, 7/29/99, 8/5/99
6/3/99, 6/10/99
8/12/99
9/2/99, 9/9/99, 9/23/99, 10/7/99, 10/21/99
1/26/99, 1/27/99, 1/28/99, 2/03/99, 2/04/99, 2/05/99
2/23/99, 2/24/99, 2/25/99, 3/02/99, 3/03/99, 3/04/99, 3/09/99, 3/11/99,
3/12/99, 3/16/99, 3/17/99, 3/18/99, 3/23/99, 3/24/99, 3/25/99, 3/30/99,
3/31/99, 4/01/99
10/13/98, 10/15/98, 10/27/98, 10/29/98, 11/03/98, 11/05/98, 11/10/98,
11/12/98,
11/17/98, 11/19/98
10/20/98, 10/22/98
12/19/98, 12/21/98
2/09/98, 2/11/98, 2/16/99, 2/18/99, 2/23/99, 2/25/99, 3/02/99, 3/04/99,
1/26/99, 1/28/99
8/3/99, 8/17/99, 8/24/99, 8/31/99, 9/7/99, 9/28/99, 10/12/99, 10/26/99,
11/2/99, 11/9/99, 11/16/99, 11/23/99, 11/30/99, 12/7/99, 12/14/99,
1/4/00, 1/11/00, 1/18/00, 1/27/00
6/1/99, 6/8/99, 6/15/99
Observations: The skills based training has improved the maintenance and instrumentation associates’ level
of knowledge in their assigned crafts. All associates scored higher than 60 percent on their final examination
for the TTC training program. This is an improvement over the original skills assessment test scores where
55 percent of the associates scored below 60 percent. The program was an overall success and has improved
basic skills knowledge among the associates.
Improvement Program HA.6006-Skills Based Training Program:
Objective HA.6006.2: Increase basic familiarity and reliability of performing CMMS task instructions.
Target HA.6006.2: Through in-house training, maintenance associates to train on 24 revised task
instructions by December 31, 2000.
Target Met: Not met. Justification memo to file. New target date for completion January 31, 2001.
F-9
SAMPLE DOCUMENTATION
Results: Completed training on 12 revised task instructions as of December 2000. Oversight on number
required. Reported in the HWTP Monthly Report HA.7002.M.Yr.
Observations:
This training program involved all maintenance associates and helped establish a better understanding of
revised maintenance task instructions within the CMMS. Failure to meet prescribed target was due to
oversight during training schedule preparation.
Improvement Program HA.6006-Skills Based Training Program:
Objective HA.6006.3: Increase reliability and flexibility for taking data points on the vibration analysis
routes.
Target HA.6006.3: Through hands-on training and taking one set of data collections, train two Maintenance
Associates and or I&E Associates by December 31, 2000.
Target Met: June 2000
Results: Table 2 summarizes Hanahan WTP Maintenance Associates and I&E Associates training. Reported
in the HWTP Monthly Report HA.7002.M.Yr.
Table 2
Hanahan WTP Maintenance and I&E Associates
February to December 2000
Associates
Name
Maintenance
IRD Software
Training
H-VIBCHM-01
H-VIBGIB-01
H-VIBMCCL-O1
H-VIBPSTA-01
H-VIBSHP-01
H-VIBSTN-01
David Kranz
2/22-24/00
4/25/00
5/23/00
5/23/00
6/01/00
4/25/00
5/02/00
Lynn Shelton
2/22-24/00
3/28/00
2/22-24/00
3/28/00
6/01/00
4/25/00
5/02/00
6/01/00
4/25/00
5/02/00
Chris Peters
4/25/00
I&E
Jack Fairbourn
2/22-24/00
3/28/00
4/25/00
5/23/00
Observations: None.
F-10
5/23/00
SAMPLE DOCUMENTATION
Improvement Program HA.6006-Skills Based Training Program:
Objective HA.6006.4: Increase skill level of Laboratory Chemists through training on our specific brand of
Atomic Absorption Unit.
Target HA.6006.4: Through Maxwell Instruments two-day on site training program for the TJA Atomic
Absorption Unit increase skill level of Chemists by September 30, 2000.
Target Met: May 2000
Results: The training was scheduled and performed on May 30. Three employees attended the five hour
class: Lisa Myers, Chris Mantooth, and Mike Lindley. Reported in the HWTP Monthly Report
HA.7002.M.Yr.
Observations: None.
Improvement Program HA.6006-Skills Based Training Program:
Objective HA.6006.5: Establish a standard method of recording and documenting any training received by
HWTP Associates.
Target HA.6006.5: Establish use of CPW’s Skills Based Training software. Include all current information
required to complete SBT data fields for HWTP Associates and train Administration Staff by August 31,
2000.
Target Met: Not met. Objective and Target closed July 2000.
Results: Objective and Target closed. Reported in the HWTP Monthly Report HA.7002.M.Yr.
Observations: Justification memo to file. Poor software support for ease of use and reporting. Will continue
to use spreadsheets until such time as training record database can be developed using standard MS software.
Filter Media
Improvement Program HA.6001-Water Treatment Plant Pilot Study Program:
Objective HA.6001.1: Evaluate existing filter media for turbidity removal efficiency in preparation for
proposed lower turbidity standard.
Target HA.6001.1: Final report to D&C Engineer to initiate project by May 31, 2000.
Target Met: May 2000
Results: Completed evaluation report and distributed to D&C May 2000. Reported in the HWTP Monthly
Report HA.7002.M.Yr.
Observations: Evaluation report recommended replacement of existing media in favor of new anthracite and
sand design. Major capital project implemented using current funds from major capital and recurring capital.
F-11
SAMPLE DOCUMENTATION
Chemical Systems
Improvement Program HA.6002- Net Recurring Capital Improvements Program:
Objective HA.6002.95400212: Improve chemical feed and handling systems.
Target HA.6002.95400212: Complete project by June 30, 2001.
Target Met: Incomplete. Carried over to 2001.
Results: Plans and specifications complete awaiting negotiated bid results. Reported in the HWTP Monthly
Report HA.7002.M.Yr.
Observations: Some delays because project combined with other plant improvement needs.
Monitoring & Testing:
Improvement Program HA.6002- Net Recurring Capital Improvements Program:
Objective HA.6002.00400011: Diesel fuel leak detection system.
Target HA.6002.00400011: Complete project by March 31, 2001.
Target Met: Incomplete. Carried over to 2001.
Results: 99 percent of field equipment installed. Awaiting explosion proof isolators. Reported in the
HWTP Monthly Report HA.7002.M.Yr.
Observations: Project expected to be complete upon completion of new plant SCADA system. New
SCADA screens complete for monitoring diesel fuel leak detectors.
Improvement Program HL.6008-Laboratory Information Management System (LIMS):
Objective HL.6008.4: Improve data handling, retrieval and report generation and tracking quality control.
Target HL.6008.4: Research options, write specifications, solicit proposals, and issue PO by December 31,
2000.
Target Met: June 2000.
Results: Our Finance Department contacted DHEC and determined that we could also qualify for state
contract pricing under DHEC’s competitive bid process. We obtained a quote from Labworks and compared
it to the quote obtained from DHEC and determined that the unit pricing was the same. A requisition was
completed (#98002416) and entered into the CPW FMS system for approvals and issuance of a PO.
Reported in the HWTP Monthly Report HA.7002.M.Yr.
F-12
SAMPLE DOCUMENTATION
Observations: None.
Process Operations:
Improvement Program HA.6010- Partnership Program:
Objective HL.6010.1: Complete Phase III Self Assessment under requirements of the Partnership for Safe
Water guidelines.
Target HL.6010.1: Submit Phase III Self Assessment Report by June 30, 2001.
Target Met: Incomplete. Carried over to 2001.
Results: No activity, awaiting appropriate staffing to complete. Reported in the HWTP Monthly Report
HA.7002.M.Yr.
Observations: Delayed due to difficulty meeting staffing needs.
Conclusions:
Overall the Improvement Programs implemented to date have been successful. Each contributed
significantly to environmental management, continual environmental improvement, productivity
improvement, and environmental stewardship. Some of these programs have produced improvements above
their original scope. An example of this is the valve identification program where main valves are marked
with unique identifiers developed as a result of the program to allow quick valve identification for
emergency procedures. Another example is the updated vibration analysis software and new laboratory
information management software.
The improvement programs have also provided the associates an opportunity to improve their skills and job
knowledge. The results are increased associate ownership in task instructions and confidence in the essential
job functions for each associate involved in the program. This program has also provided a basis for cross
training between crafts and will give associates the opportunity to raise their skills and knowledge of other
crafts providing CPW with multi-skilled associates and work force flexibility.
The Improvement Programs provided was the opportunity for teamwork throughout the treatment plant and
created a common set of goals for all departments to accomplish. Encouragement of teamwork and
organization is a huge benefit derived from the improvement program which will promote an environment of
continued improvement.
F-13
SAMPLE DOCUMENTATION
Compliance Assessment
Sample Compliance Assessment Procedure – Charleston Public Works Commission
F-14
SAMPLE DOCUMENTATION
CPW ENVIRONMENTAL MANAGEMENT SYSTEM
PROCEDURE
The on-line version and secured hardcopy are the controlled documents. The secured hardcopy will
be identified by an “Official Document” stamp giving date of distribution. Any and all other
documents are uncontrolled. Contact the EMS Program Manager for revision level status.
Effective Date:
Revision: 1
Title:
October 1, 2000
Identification Number: EMS – 4.5.1 (C)
Regulatory Compliance Procedure
Prepared By:
Reviewed By:
EMS Procedures Subcommittee
EMS Management Steering Committee
Approved By:
William E. Koopman Jr., General Manager
John Cook PE, Assistant General Manager
August 25, 2000
Date Approved:
0.0 Requirement
Page 1 of 3
ISO 14001, Sub Clause 4.5.1 Monitoring and Measuring
1.1 Purpose
To establish and maintain a documented procedure for periodically evaluating compliance with relevant
environmental legislation and regulations.
2.1 Scope
2.1 ISO 14001, sub clause 4.5.1 requires evaluations to be performed on a periodic basis to assess
compliance with environmental regulations.
2.2 This procedure applies to all CPW departments.
4.0 Responsibility and Authority
3.1 It is the responsibility of the department head to ensure that self-assessments of compliance with
environmental regulations and other legal environmental requirements of EMS procedure 4.3.2 are
scheduled and conducted and that assessment results are documented.
3.2 It is the responsibility of CPW associates to notify their supervisor upon discovery of a regulatory
non-compliance condition.
F-15
SAMPLE DOCUMENTATION
Effective Date:
Revision: 1
Title:
October 1, 2000
Identification Number: EMS – 4.5.1 (C)
Regulatory Compliance Procedure
Page 2 of 3
3.3 It is the responsibility of the department head to ensure that regulatory non-compliance(s) are
reported to executive management and the applicable regulatory agency as specified by the regulatory
requirement.
3.4 It is the responsibility of the department head to follow-up with corrective action(s) on regulatory
non-compliance(s), to return the facility to compliance as expeditiously as possible, and to document
all corrective actions taken.
5.0 Procedure
4.1
Scheduling
The department head (or designee) will develop a self-assessment schedule, established on a once
per quarter frequency, to assess regulatory compliance.
4.2
Site Inspection
The department head (or designee) will inspect selected site(s), observe operating conditions,
interview associates on work activities and operating conditions and record observations in a
factual way based upon regulatory and other legal requirements. Review of selected regulatory
records, measuring and calibration records, operating criteria or standard operating instructions,
shall take place before, during, and/or after the inspection.
4.3
Corrective Action Plan
The department head will promptly initiate corrective actions to resolve the regulatory noncompliance. In accordance with EPA’s 1995 Policy on Voluntary Discovery, if non-compliance
cannot be corrected within a sixty (60) day period, a Corrective Action Plan will be developed.
A copy will be forwarded to the section head, the EMS program manager and executive
management.
4.4
Follow-up
The department head will conduct a follow-up surveillance upon completion of the corrective
measures taken. If a Corrective Action Plan was developed, then a finding of closure will occur
immediately upon verification of corrective action. A copy of the closure report will be
submitted to the section head, EMS program manager and executive management.
F-16
SAMPLE DOCUMENTATION
Effective Date:
Revision: 1
Title:
October 1, 2000
Identification Number: EMS – 4.5.1 (C)
Regulatory Compliance Procedure
Page 3 of 3
Access to these records is privileged pursuant to Code of Laws of South Carolina, Section 48-57-10 et. seq.,
“Environmental Audit Privilege and Voluntary Disclosure.” Distribution of the environmental selfassessment report is restricted to executive management, EMS program manager and relevant individuals
within the department.
4
Related Documentation and Records
5.1
5.2
5.3
5.4
5.5
5.6
Master List of Legal Requirements
Department Standard Operating Instructions and Records
Self Assessment Schedules
Self Assessment Reports
Corrective Action Plans
Follow-up/Closeout Records
F-17
SAMPLE DOCUMENTATION
Calibration
New Hampshire Department of Transportation – Traffic Bureau
F-18
SAMPLE DOCUMENTATION
Number: EMS-CH500-System-54-12
Title:
Calibration/Maintenance Management Procedure
Date of Adoption:
Date of Revision:
Prepared By:
Reviewed By:
Approved By:
EMS Program Manager
Implementation Team
Lyle W. Knowlton
Director of Operations
Document Control:
_____ The secured hard copy signed, dated, and stamped “Official
Document” shall be the controlled document and shall be
maintained by Hearings Examiner.
_____ This document and the on-line version are copies of the secured
hard copy controlled document.
_____ Duplicate copies may be made and distributed, however, users must
assure themselves the copied document is the current controlled
copy.
_____ Earlier versions of this document are obsolete and should be
removed from points of use.
Distribution:
_____ NHDOT intranet; bulletin boards ______________
_____ Administrators: _______________________________
_____ Supervisors: __________________________________
_____ Employees: ___________________________________
_____ Other: ________________________________________
Amendments:
Summary:
1.0 Purpose…………………………………………………………………
2.0 Scope and Applicability…………………………………….
3.0 Reference………………………………………………………………
4.0 Policy Statement……………………………………………………
5.0 Specific Responsibilities.…………………………………………
5.1 Bureau Administrator……………………………………………
5.2 Supervisor……….…………………………………………………
5.3 Employee………………….……………………………………
6.0
Operational Procedure….………………………………………
2
2
2
2
3
3
3
3
3
7.0 Audit and Review…………………………………………………
4
7.1 Items Subject to Audit and Review…………………………….. 4
7.2 Record Keeping; Format; Destruction………………………… 4
7.3 Responsibility for Audit and Review ………………………… 4
8.0 Personnel Actions…………………………………………………… 5
8.1 Discipline…………………………………………………………… 5
9.0 Other…………………………………………………………………
5
1.0 Purpose
In accordance with ISO 14001, § 4.4.6, the Bureau has established and adopted the following procedure.
F-19
SAMPLE DOCUMENTATION
This procedure is to ensure the calibration/maintenance requirements of the Bureau’s operational and
monitoring equipment are performed in accordance with applicable O & M manuals, standard operating
instructions and/or manufacturers recommended standards., and that the operational and monitoring
equipment is in compliance with the relevant environmental and regulatory requirements.
2.0 Scope and Applicability
This procedure applies to the Bureau of Traffic and its statewide operations.
3.0 Reference
Environmental Policy
ISO 14001 § 4.4.6
EMS Significant Aspects System Procedure
EMS Training, Awareness and Competence System Procedure
EMS Document Control System Procedure
EMS Objectives and Targets System Procedure
EMS Legal and Other Requirements System Procedure
Relevant standard operating procedures for equipment used at Traffic
Material Safety Date Sheets
4.0 Policy
It is the policy of the Bureau to assure its operational and monitoring equipment is calibrated and
maintained to assure its performance in aiding the Bureau in meeting the objectives and targets of its
significant aspects.
5.0 Specific Responsibilities
5.1 Bureau Administrator
The Bureau Administrator is responsible for the calibration and maintenance program and assuring the
employees have the necessary tools and training to perform the required calibration and maintenance
tasks.
The Bureau Administrator is responsible for the development, revision, and issuance of appropriate
calibration/maintenance standard operating instructions.
The Bureau Administrator shall ensure that the results of calibration and maintenance efforts are
documented.
5.2 Supervisor
Section Supervisors are responsible for assuring monitoring equipment is calibrated to appropriate
specifications and operational equipment is properly maintained before its use.
Section Supervisors shall notify the Bureau Administrator of any problems with the
calibration/maintenance of monitoring/operational equipment, and will set in motion a corrective action
plan that will return their section’s equipment to complete compliance as soon as is practicable.
Section Supervisors are responsible for keeping maintenance records and for forwarding such reports to
the Bureau Administrator for quarterly reports.
5.3 Employee
It is the responsibility of all employees to notify their supervisor when they discover any problems with the
monitoring/operational equipment.
F-20
SAMPLE DOCUMENTATION
6.0 Operational Procedure
a. The Bureau Administrator, or his designee, shall, on a quarterly basis, document the
calibration/maintenance activities.
b. The Bureau Administrator, or his designee, will direct the drafting of calibration/maintenance
standard operating instructions for its monitoring/operational equipment. These instructions will
include or reference the following information where relevant.
Standard Operating Instruction Title
Document Identification Number
Revision date and approval
Detailed maintenance criteria
Schedule and frequency of maintenance activities
Procedural instructions on start up
Procedural instructions on shut down
Emergency operation
Inspection and test instructions
Corrective repair maintenance instructions
Preventative maintenance procedures
Safety requirements
Location of manufacturer’s reference material
c. Following review by the Implementation Team and appropriate supervisors, the Bureau
Administrator issues the approved instructions.
d. The Bureau Administrator ensures the supervisors and relevant maintenance personnel receive the
appropriate training for their maintenance tasks, including training on the environmental impacts
or potential consequences in deviating from the specified standard operating instructions on critical
equipment and processes.
7.0 Audit and Review
7.1 Items Subject to Audit and Review
At least annually, the Bureau Administrator shall review this procedure to ensure the purposes for which it
was created are being met in an efficient manner.
7.2 Record Keeping; Format; Destruction
a. A copy of this procedure shall be maintained in the records of the Bureau of Traffic and each
relevant unit supervisor.
b. This document is a controlled document. The on-line version and
secured hard copy are the controlled documents.
c. The secured hard copy, stamped “Official Document” and dated,
shall be maintained by Hearings Examiner.
d. Changes and updates to this procedure, and filing and destruction requirements shall be noted on all revisions to the
original copy, and all paper copies distributed to the Bureau of Traffic.
7.3 Responsibility for Audit and Review
The EMS Program Manager and the Bureau Administrator shall review compliance with this procedure at
such intervals as they deem appropriate, but no less than annually. A written report discussing
compliance with this procedure shall be provided to the Commissioners as directed, but no less often than
annually.
F-21
SAMPLE DOCUMENTATION
8.0 Personnel Actions
8.1 Discipline
As a condition of employment, all employees of the State of New Hampshire Department of Transportation
are required to participate actively in Environmental Management System programs and follow established
policies, procedures, instructions, and/or rules. Cooperation between management and employees is
necessary to meet this work standard. Disciplinary action, up to and including dismissal, will be taken in
cases where it is determined that disregard for environmental responsibilities has occurred. Disciplinary
action will be taken in accordance with the New Hampshire Division of Personnel Administrative Rules,
Chapter 1000.
9.0 Other
Reserved.
F-22
SAMPLE DOCUMENTATION
Nonconformance
and
Corrective and Preventative Action
Sample nonconformance and corrective and preventative action procedure –
City of Eugene, OR
F-23
SAMPLE DOCUMENTATION
Controlled
Document
CITY OF EUGENE – WASTEWATER DIVISION
Procedure
Subject:
Nonconformance and Corrective Action
Prepared
By:
Sharon Olson
Date Prepared:
Approved By:
Management Team
Date Approved:
Document No:
WW-00016R1
6/26/00
Revision Date:
7/31/01
8/6/01
Next Review Date:
8/1/02
Purpose
This procedure describes the process to ensure that the Division establishes, maintains and uses a system to
identify nonconformances from regulations and requirements and to specify a corrective action process to
identify and track areas for corrective action.
Scope
This procedure applies to all nonconformances requiring corrective action by staff. These will typically identified by the following
methods:
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Internal and external audits
Environmental Compliance Audits
Safety Audits
Inspections
Incident Reports
Complaints
Compliance Inspections
Permit Inspections
Definitions
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Audit Team
Corrective Action Request (CAR)
Environmental Compliance Assessment
EMS
EMS Manager
External Auditors
Nonconformance
Safety Requirements
All specific safety requirements will be included or referred to in specific work instructions.
F-24
SAMPLE DOCUMENTATION
Procedure (Include reporting requirements and precautionary steps in this section)
Accountability:
Responsibility:
Division Management Team
Provide appropriate resources to ensure nonconformances are corrected.
Audit Team
Conduct conformamnce audit/internal or external assessment.
Audit Team
Staff
Identify potential nonconformance and notify supervisor and Audit Team member by email.
Audit Team
Determine whether the potential nonconformance meets the criteria for a nonconformance
and if so generate corrective action request.
Complete corrective action request form (CAR) and provide copy of form to Lead
Auditor.
Lead Auditor
Submit CAR information to EMS Manager, and Document Control.
EMS Manager
Review corrective action request information and inform Division Management Team of
any identified nonconformance that involves a potential regulatory or legal
noncompliance.
Determines appropriate staff to take corrective action. Notify appropriate staff and
request corrective action.
Division Staff
Identify the cause of the nonconformance.
Identify appropriate corrective action. Complete Corrective Action Approval Request
Form and forward electronically to EMS Manager, with copy to work section supervisor
(if supervisor does not complete form).
EMS Manager
Reviews Corrective Action Approval Request Form . Requests additional information if
necessary. Approves recommended corrective action.
Implement the necessary corrective action.
Division staff
Notify EMS Manager on completion of necessary corrective action. Include completed
Corrective Action Completion Check List form.
EMS Manager
Closes corrective action.
Document Control
Maintain records of all non-compliance and corrective action request forms
Internal Auditors
Include review of completed corrective actions in scope of audits.
References
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ISO 14001 Standard, 4.5.2 Non-conformance and Corrective and Preventive Action
EMS Manual, Nonconformance and Corrective Action Policy
Internal Audit Procedure
Monitoring and Measuring Procedure
Corrective Action Approval Request Form
Corrective Action Completion Checklist Form
Corrective Action Request (CAR) Form
F-25
SAMPLE DOCUMENTATION
Corrective Action/Preventative Action Form
Jefferson County, AL
F-26
SAMPLE DOCUMENTATION
JEFFCO
CORRECTIVE ACTION NOTICE
This CAN is in Response to:
Internal Audit:
∠
Nonconformance No.:
3rd-Party Audit:
∠
Audit Team Leader:
Management Review:
Audit Team Member/Requestor:
Department:
Division:
Date:
Standard & Clause:
Major:
Minor:
∠ Other: ∠
Observation:
Auditee Representative/Recipient:
Document Reference:
Nonconformance Statement:
Root Cause:
Corrective Action Response (to be completed by Auditee):
Proposed Completion Date:
Actual Completion Date:
Auditee Representative:
Corrective Action Taken:
Clearance Action (to be completed by Environmental Management Representative)):
Accepted:
Y
N
Downgraded:
Follow-Up Comment:
F-27
Y
N
SAMPLE DOCUMENTATION
JEFFCO
PREVENTIVE ACTION NOTICE
This PAN is in Response to:
Internal Audit:
†
Nonconformance No.:
3rd-Party Audit:
…
Management Review:
Audit Team Leader:
Audit Team Member/Requestor:
Department:
Division:
Date:
Standard & Clause:
Major:
Minor:
… Other: …
Observation:
Auditee Representative/Recipient:
Document Reference:
Nonconformance Statement:
Preventive Action Response (to be completed by Auditee):
Proposed Completion Date:
Actual Completion Date:
Auditee Representative:
Preventive Action Taken:
Clearance Action (to be completed by Environmental Management Representative):
Accepted:
Y
N
Downgraded:
Follow-Up Comment:
F-28
Y
N
SAMPLE DOCUMENTATION
Internal EMS Audit
Internal EMS Audit Procedure – City of Berkeley, CA
Internal EMS Audit Report – City of Berkeley, CA
EMS Audit Checklist – Jefferson County, AL
F-29
SAMPLE DOCUMENTATION
ISO 14001 Reference: 4.5.4 EMS Audit
Location: Central Files EMS: System Procedures
Revision: 00.03.19.02
Created By: EMS PM
Review Schedule: Biennially
March 19, 2002
SYSTEM PROCEDURE
EMS INTERNAL AUDIT
1.0
PURPOSE
This procedure defines the process for conducting periodic audits of the Solid Waste Management Division Environmental
Management System. The purpose of the audit includes but is not limited to determining continued conformance with ISO 14001
and other requirements and that the EMS is properly maintained and documented.
2.0
SCOPE
This procedure applies to the Solid Waste Management Division and its operations.
3.0
DEFINITIONS
3.1
EMS Audit: a periodic process to assess the EMS against the ISO 14001 requirements and against the divisions
EMS documentation and records.
3.2
Lead Auditor: an auditor who is authorized to plan, organize, and direct EMS audits in the Division. The Lead
Auditor will report findings and observations, and evaluate the adequacy of corrective and preventive action.
The lead auditor should be appropriately trained for this purpose.
3.3
Audit Finding: results of the evaluation of the audit evidence compared with the ISO 14001 criteria. This
could be a nonconformance or an observation.
3.4
Nonconformance: a deficiency or failure to meet the standards of ISO 14001. May be a minor missing system
component, an isolated incident or any number of incidents that lead to the failure to conform completely with
ISO 14001 as it relates to this facility.
3.5
Observation: a practice or the absence of a practice, while not in violation of ISO 14001, could strengthen the
system or cause a system failure.
3.6
Corrective Action Request (CAR): as a result of the audit findings, CARs are assigned to all nonconformances
to correct all environmental problems as they occur. This measure may also be used to correct safety and other
issues on this facility.
3.7
Preventive Action Request (PAR): as a result of audit findings, PARs are assigned to any observation made
that may prevent potential environmental problems before they occur.
4.0
RESPONSIBILITY
It is the responsibility of the Environmental Program Manager to routinely schedule audits and recruit or assign an internal audit
team according to this procedure.
4.1
Specific Responsibilities
4.1.1 Environmental Program Manager
The Environmental Program Manager (EPM) is responsible for developing the yearly audit schedule in June for the coming fiscal
year, initiating internal audits and recruiting or assigning an audit team.
The EPM will maintain EMS audit records, including a list of auditors, audit schedules and procedures and all audit reports. The
EPM will select the Lead Auditor who will be exempt from the day-to-day operations of the division during the audit cycle.
4.1.2 Lead Auditor
The Lead Auditor (LA) is responsible for notifying, organizing, planning, training and directing the Audit Team prior to and
during the EMS audit.
The LA shall schedule and facilitate all Audit Team meetings, which consist of the opening, closing and any briefing meetings
required.
F-30
SAMPLE DOCUMENTATION
ISO 14001 Reference: 4.5.4 EMS Audit
Created By: EMS PM
Location: Central Files EMS: System Procedures
Review Schedule: Biennially
Revision: 00.03.19.02
March 19, 2002
The LA initiates the corrective action or preventive action process and prepares the noticies. The LA will prepare the audit team to
conduct any follow up audits needed and will prepare the final audit report, summary of findings and forward it to the EPM.
4.1.3 Auditors
Auditors are responsible for collecting, analyzing and documenting objective evidence through interviews, document examination
and visual observation during the audit investigation. They shall record their observations and findings and assist the Lead Auditor
in the preparation of CARs or PARs.
4.1.4 Division Manager
The Division Manager shall provide appropriate resources to support the EMS and its audits. The Division Manager shall report
progress or findings to upper management and other interested parties.
4.1.5 Senior Refuse Supervisors
The Senior Refuse Supervisors shall provide appropriate resources to conduct the audit such as staff time, workspace and records
as needed. The Senior Refuse Supervisors are responsible for ensuring the prompt and effective resolution of any corrective or
preventive action audit findings and for ensuring there is no reoccurrance.
4.1.6 Refuse Supervisors
Refuse Supervisors shall facilitate the audit in any way necessary and assign an audit guide if needed. Refuse Supervisors are
responsible for implementing the corrective or preventative action identified in the audit and for thoroughly training employees
under their supervision.
4.1.7 Employees
It is the responsibility of all employees to perform their job in accordance with the appropriate operating instructions and for
notifying their supervisor whenever they discover problems that may adversely affect the EMS or our legal and safety
requirements.
5.0
PROCEDURE
Based upon the fiscal year audit schedule, the audit process shall proceed as follows:
5.1
Audit Plan
5.1.1
The Environmental Program Manager shall notify the Division Manager, the Lead Auditor and the
Audit Team of the proposed audit. The Audit Team should represent a broad section of the division
activities so that individuals can be assigned to areas they do not manage or work in.
5.1.2
The Lead Auditor reviews previous audit report findings and the status of CARs or PARs prior to
preparing the audit plan. Areas identified by previous audits for corrective or preventive action should
be included in the scope of the audit.
5.1.3
Lead Auditor completes the audit plan. The audit plan includes the date, audit number, Scope and
Objective, specify sections of ISO 14001 being audited and areas of the facility being audited, an audit
schedule with auditor assignments, questionnaires and Nonconformance Report. Auditors may modify
the scope and plan if necessary. These changes must be documented.
5.2
Conducting the Audit
5.2.1
The Lead Auditor shall convene the opening meeting to brief the Audit Team on the general scope of
the audit, the details of the audit plan, receive input on the audit plan and schedule and discuss
assignments.
5.2.2
Review key EMS documentation before touring the site and conducting interviews. Records that shall
be reviewed include but are not limited to:
™ Environmental Policy
™ System Procedures
™ EMPs
™ EMS audit reports
™ Results of Management Reviews
™ Status of compliance with voluntary requirements
F-31
SAMPLE DOCUMENTATION
ISO 14001 Reference: 4.5.4 EMS Audit
Created By: EMS PM
Location: Central Files EMS: System Procedures
Review Schedule: Biennially
Revision: 00.03.19.02
March 19, 2002
™ Other relevant documents requested by Lead Auditor, Environmental Program Manager, Division
Manager or other upper management.
5.2.3
Tour the site.
5.2.4
Interview staff and observe activities and conditions. Responses and evidence shall be documented.
5.2.5
Look for evidence to verify information from interviews through observations, records or independent
sources paying particular attention to items previously identified for corrective or preventative action or
findings from other audits.
5.2.6
The Audit Team shall then meet and report on audit progress as directed by the audit plan and schedule.
5.2.7
Findings and observations will be documented by the Lead Auditor; including any corrective action
taken during the audit. An internal audit report is drafted in preparation for the closing meeting.
5.2.8
The Lead Auditor conducts the closing meeting to present audit findings, clarify any conflicting or
confusing information, identify positive practices, review objective evidence that supports the findings,
and summarize the audit results.
5.3
Reporting Audit Results
5.3.1
After the closing meeting, the Lead Auditor prepares the final audit report. The final audit report
includes a summary of the audit scope, identifies the audit team, describes the source of evidence used,
summarizes the findings and results. Copies of the final report will be submitted to the Environmental
Program Manager, the Division Manager and the EMS file.
5.3.2
For findings that require long-term corrective action, the Lead Auditor will prepare a CAR notice and
place a copy in the EMS record system. The original will be assigned to the appropriate staff person by
the Division Manager, Senior Refuse Supervisor or Refuse Supervisor as appropriate for
implementation.
5.3.3
The Division Manager ensures the availability of the audit report(s) for Management Review.
5.4
Audit Followup
5.4.1
The Division Manager and Senior Refuse Supervisors are responsible for any follow-up actions needed
as a result of the audit.
5.4.2
The EPM is responsible for tracking the progress and effectiveness of corrective actions.
5.5
Record Keeping
5.5.1
A copy of this procedure shall be maintained with the records of the division and with each relevant
staff person.
5.5.2
Records shall be maintained according to the City of Berkeley Records Retention Schedule.
5.5.3
The official document will have original signatures and be located in the EMS Manual in the office of
the Division Manager.
5.5.4
Changes and updates to this procedure will be made in accordance with our Document Control System
Procedure and Record Management System Procedure.
6.0
AUDIT AND REVIEW
The Environmental Program Manager and the Division Manager shall review conformance with this procedure at such intervals as
they deem appropriate, but no less than biennially. At least biennially the Division Manager shall review this procedure to ensure
it is still relevant and meets the needs of the division.
7.0
PERSONNEL ACTION
All employees are required to comply with all established policies and procedures of this division, the Department of Public
Works, the City of Berkeley and all local, state and federal regulations pertaining to this facility. Disciplinary action will be
recommended up to and including termination in accordance with established City of Berkeley procedures and SEIU Local 790,
Local 535 and Local 1 labor union contracts.
8.0
REFERENCE
Public Works Environmental Policy
EMS Manual
ISO 14001 Documentation
F-32
ISO 14001 Reference: 4.5.4 EMS Audit
Location: Central Files EMS: System Procedures
Revision: 00.03.19.02
Created By: EMS PM
Review Schedule: Biennially
March 19, 2002
EMS Program Manager - Preparer
Date
Environmental Program Manager
Date
Sr. Refuse Supervisor - Reviewer
Date
Sr. Refuse Supervisor - Reviewer
Date
Division Manager - Approval
Date
F-33
SAMPLE DOCUMENTATION
ISO 14001 Reference: 4.5.4 EMS Audit
Location: Central Files EMS: System Procedures
Revision: 00.03.19.02
Created By: EMS PM
Review Schedule: Biennially
March 19, 2002
SAMPLE DOCUMENTATION
Solid Waste Management
October 31, 2002
Internal Audit Report
STANDARD:
SCOPE:
ISO 14001
Assess the Environmental Management System (EMS) compliance to the ISO 14001 Standard.
The audit covers EMS documentation.
Audit Team:
Team
Wanda Redic, Lead Auditor
Rogelio Marquina
Joe Smith
The following Internal Audit Report is an appraisal of the Environmental Management System. This audit was
conducted Monday, March 18, 2002. This audit was conducted to verify conformance to the ISO 14001 standard.
In accordance with our annual audit plan the focus elements were:
4.2 [Environmental Policy], 4.4.2, [Training, Awareness and Competence], 4.4.5 [Document Control], 4.4.6
[Operational Control], & 4.5.3 [Records]. The specific areas of the Standard that were audited are detailed in the
attached schedule.
SUMMARY:
The audit evaluated the conformance of the EMS to the requirements of ISO 14001. There were several major
findings that were documented. Observations were made and also documented.
This is the first in a continuing series of internal audits. Therefore, there were no outstanding CAR’s to be evaluated
during this audit.
The audit results reflect an on-going need for management to emphasize that ISO 14001 conformance requires daily
adherence to all our level procedures, intensified training, management review and signatures on all documentation.
ISO conformance relies on each individual employee as well as all respective levels of management in order to
maintain the Environmental Management System. This emphasis should focus on ensuring all levels of the work
force understand the environmental policy, have implemented the environmental system, and are working daily to
maintain that environmental system.
A summary of the CAR’s is attached in Appendix A. Each CAR will soon be available on the Division directory.
Each CAR will be discussed with the appropriate Supervisor regarding the nonconformance and what measures are
needed to resolve the finding. CAR assignees will be asked to sign their CAR & agree upon a completion date.
F-35
SAMPLE DOCUMENTATION
Supervisors are strongly encouraged to begin immediate corrective action. The Corrective Action Procedure is
under development and will be distributed upon completion.
Appendix B contains the Agenda and Attendance List for the audit Opening and Closing Meetings. The audit
schedule is presented in Appendix C.
F-36
SAMPLE DOCUMENTATION
ISO 14001 Audit Findings (Summary)
March 2002 Internal Audit
Monday, March 18, 2002
Auditor
Rogelio Marquina
ISO Clause
4.3.1
ISO Section
Env. Aspects
Findings [Corrective Action]
Finding: Non-conformance. Update
system procedure to include update
procedure for environmental aspects.
Wanda Redic
4.3.4
EMPs
Wanda Redic
4.4.1
Structure &
Responsibility See
Question 2 & 3 of
Audit Protocol
Finding: Observation. Documents need
review for completion and signatures.
Finding: Observation. Org. chart exists
but is not documented in the EMS
records. Include report for Gen. Section
with details of staff involvement.
Wanda Redic
4.4.4
Documentation
Wanda Redic
4.4.7
Wanda Redic
4.4.7
Wanda Redic
4.5.2
Wanda Redic
4.5.3
Wanda Redic
Wanda Redic
4.5.4
4.6
Emergency
Preparedness
Emergency
Preparedness
Non-Conformance
& Corrective
Action
Records Storage |
Records Identified
& Traceable to
Activity
EMS Audit
Management
Review
Finding: Observation. Suggestion:
Add to General Requirements the ISO
14001 Standard requirements for
reference. Place org charts in this
section as well.
CAR: Periodic testing of emergency
procedures not implemented.
CAR: Procedures do not provide means
to identify potential accidents.
CAR: No procedure on record.
CAR: Records are not filed
consistently. Records in multiple
locations & not readily accessible.
Records poorly maintained.
CAR: No procedure on record.
CAR: No procedure on file.
Note: This is the first EMS
implemented. Management Review
will be conducted when all documents
conform to ISO 14001.
F-37
SAMPLE DOCUMENTATION
Corrective Action Request’s [CAR]
0 CARS evaluated. 0 Closed, 0 Implemented, 0 progressing toward Implementation, & 0 had no change since last audit.
Status:
C= Closed I= Implemented
OK= Progress made NC= No Change
#= # of days open
Corrective CAR’s.
Administration Responsibility
CAR #
RM - 1
Element
Status
Transfer Station Responsibility
CAR #
Element
WR - 2A
4.4.7
Status
Collections Responsibility
CAR #
Element
Status
4.3.1
WR - 1
4.4.7
WR - 2
4.4.7
WR - 3
4.5.2
WR - 4
4.5.3
WR - 5
4.5.4
WR - 6
4.6
* Lack of timeliness CAR.
Preventive CAR’s.
Administration Responsibility
Preventive CAR #
Element
Status
Transfer Station Responsibility
Preventive CAR #
Element Status
Operations Responsibility
Preventive CAR #
Element
NOTE: The above is not a complete listing of ISO 14001 CAR’s, Only the findings of the internal desk audit are included.
{database status (as of 3/18/02) shows total of 0 open CAR’s [0 corrective, 0 preventive]}.
For additional information or copies of CAR documents, please refer to the “CAR Database” in the Access 2000 database (under construction).
F-38
Status
SAMPLE DOCUMENTATION
Solid Waste Management
OPENING MEETING
Internal ISO 14001 Audit
March 18, 2002 11:15 a.m.
It is time for our first planned internal audit. Please sign the attendance sheet.
Scope: Assess Solid Waste Management Division environmental management system compliance to the ISO 14001
Standard. The audit will include the EMS manual and procedures and conclude with the site audit on Wednesday,
March 20, 2002. Since this is our first internal audit, there are no open CAR’s to assess.
Objectives:
1.
The objective of the audit is to evaluate the overall organizational conformance to the ISO 14001 standard with emphasis on
elements: 4.2 [Environmental Policy], 4.4.2, [Training, Awareness and Competence], 4.4.5 [Document Control], 4.4.6
[Operational Control], & 4.5.3 [Records].
2.
Evaluate and verify corrective actions from previous audits. Since this is our first internal audit, there are no
corrective actions to evaluate at this time.
Copies of the ISO 14001 Checklist were provided for auditors. To verify conformance & corrective/preventive
actions we will:
Review objective evidence – work instructions & environmental records.
Perform Personal interviews with assignees, their employees, and responsible management
Discrepancies will be documented on our ISO Nonconformance Report form. This process has not yet
been documented.
Resources and facilities include Administration, Collections and Transfer Station Operations.
A Closing meeting will be held the week of Monday, April 1, 2002, in the SWMD Assembly Room. Brief training
of EMS Audit procedures using the Environmental Policy was conducted and the desk audit began.
Desk Audit completed at 12:00 p.m. - Facility Audit scheduled for Wednesday, March 20, 2002.
Hard copies of the opening meeting attendance lists are maintained in the EMS Audit Record File.
F-39
SAMPLE DOCUMENTATION
Closing Meeting Agenda
Internal Audit March 20, 2002
1.
Route and retain attendance sheet.
2.
Summary of the audit activities:
a. Scope and objective: The objective of the audit is to evaluate the overall organizational conformance to the
ISO 14001 standard. To assess conformance to ISO 14001 with emphasis on elements: 4.2
[Environmental Policy], 4.4.2, [Training, Awareness and Competence], 4.4.5 [Document Control], 4.4.6
[Operational Control], & 4.5.3 [Records]. Areas audited:
Clause
4.2
4.3.1
Title
Environmental Policy
Environmental Aspects
Clause
4.4.5
4.4.6
Title
Document Control
Operational Control
4.3.2
4.3.3
4.3.4
Legal and Other Requirements
Objectives and Targets
Environmental Management Programs
4.4.7
4.5.1
4.5.2
4.4.1
4.4.2
4.4.3
4.4.4
Structure and Responsibility
Training, Awareness, and Competence
Communication
EMS Documentation
4.5.3
4.5.4
3.
Emergency Preparedness and Response
Monitoring and Measuring
Nonconformance and Corrective and
Preventive Action
Records
EMS Audit
Review Team's conclusion regarding the desk audit. Review corrective action and report findings.
4. Summary of Nonconformances (see attached summary).
NOTE: The absence of a finding in a particular area does not mean there are none. It only indicates that this
audit did not discover anything in our particular sample. The attached findings are what were discovered in the
sample we took. Remember, CAR’s or Preventative CAR’s are not bad, they are opportunities for
improvement.
5.
Briefly explain the process for corrective action, follow-up, and closure. This process will be explained to the
executive staff at their weekly meeting. 30 days to submit C&C/A, & achieve implementation. The sooner the
C&C/A is approved the more of the 30 days you have for implementing. 3 steps to CAR closure: 1) Approved
C&CA, 2) accomplish implementation, and 3) demonstrate effectiveness.
NOTE: C & C/A updates and re-negotiation of completion dates must be performed by the auditee [Please do
this in writing, e-mail is fine].
6.
Discuss submittal of internal audit report. Project Manager/Lead Auditor will submit report to EMS Champion
and Environmental Program Manager no later than April 5, 2002
7.
8.
The rest of the EMS will be audited during the time period starting today and before the Registration Audit in
March. The final Registration Audit is scheduled for March 26-30, 2001, and is a 3rd party audit by QSR.
Thank audit team for their support and close meeting.
Positive Comments
Hard copies of the closing meeting attendance lists are maintained in the EMS Audit Record File in accordance
with the SSLP-1280-0016.
F-40
SAMPLE DOCUMENTATION
SWMD Internal EMS Audit Plan - March, 2002
Audit Plan - # 03-2002
AUDIT SCOPE AND OBJECTIVE
The scope of the audit is to assess conformance to the ISO 14001 elements.
Clause
4.2
4.3.1
Title
Environmental Policy
Environmental Aspects
Clause
4.4.5
4.4.6
Title
Document Control
Operational Control
4.3.2
Legal and Other Requirements
4.4.7
4.3.3
4.3.4
Objectives and Targets
Environmental Management Programs
4.5.1
4.5.2
4.4.1
4.4.2
4.4.3
4.4.4
Structure and Responsibility
Training, Awareness, and Competence
Communication
EMS Documentation
4.5.3
4.5.4
Emergency Preparedness and
Response
Monitoring and Measuring
Nonconformance and Corrective and
Preventive Action
Records
EMS Audit
The objective of the audit is to evaluate the overall organizational conformance to the ISO 14001 standard.
TEAM MEMBERS
Lead Auditor: Wanda Redic
Team #1
Wanda Redic – Lead Auditor
Joe Smith
Rogelio Marquina
Environmental Program Manager: Becky Dowdakin
APPLICABLE DOCUMENTATION:
Division EMS Manual
F-41
SAMPLE DOCUMENTATION
AUDIT SCHEDULE
Wednesday – Opening Meeting and Desk Audit
8:30 AM - 9:00 AM
9:00 AM – 12:00 PM
12:00 PM – 1:00 PM
1:00 PM – 4:00 PM
Opening Meeting (Auditors)
Facility Audit
Lunch
Facility Audit Conclusion
Environmental Policy
Environmental Aspects
Legal and Other Requirements
Objectives and Targets
Environmental Management Programs
Structure and Responsibility
Training, Awareness, and Competence
Communication
EMS Documentation
Document Control
Operational Control
Emergency Preparedness and Response
Monitoring and Measuring
Nonconformance and Corrective and Preventive Action
Records
Environmental Management System Audit
4.2
4.3.1
4.3.2
4.3.3
4.3.4
4.4.1
4.4.2
4.4.3
4.4.4
4.4.5
4.4.6
4.4.7
4.5.1
4.5.2
4.5.3
4.5.4
Functional Assessment
Wednesday
March 20,
2002
9:00 AM –
10:30AM
Auditor
Elements
Audited
Activity
Building/
Operation
Organization
Escort
Auditee
#1
WR
4.2, 4.3.1,
4.3.4, 4.4.2,
4.4.5, 4.4.6,
4.5.3
4.2, 4.3.1,
4.3.4 4.4.2,
4.4.5, 4.4.6,
4.5.3
Audit
Administration
Administration
N/A
Exec. Staff
#2
12:00 AM –
1:00 PM
12:45 PM –
2:45 PM
3:00 PM –
4:00 PM
Audit
Lunch
#1
4.2, 4.3.1,
4.3.4, 4.4.2,
4.4.5, 4.4.6,
4.5.3
4.2, 4.3.1,
4.3.4, 4.4.2,
4.4.5, 4.4.6,
4.5.3
Audit
Audit
#1 & #2 &
#3
Compile
Administration
Findings,
Summary &
Close Out
* The functional assessment of this audit is not limited to the elements listed under "Elements Audited"
F-42
SAMPLE DOCUMENTATION
Original signed by:
Wanda Redic,
Lead Auditor
Becky Dowdakin,
Environmental Program Manager
F-43
SAMPLE DOCUMENTATION
JEFFCO INTERNAL EMS CHECKIST
No.
Question
Y
N
Comments
Status
Environmental Policy
This section corresponds with
element 4.2 of ISO 14001 (4.1 in the
ISO 14001 standard refers to the existence of
an EMS)
1
2
Is the environmental policy defined?
Is the policy appropriate (sensible) to
the type, size and environmental
impacts of the organization’s
activities, products and services?
9
9
C
C
9
C
9
C
9
C
(The policy does not have to be many pages in
length to be comprehensive and yet meet the
EMS requirements.)
3
Does the policy include a specific
commitment to continual
improvement?
(This sub-element may have to wait for
subsequent audits to verify. Continual
improvement can be attributed to the
improvement of the EMS system itself and not a
specific performance variable.)
4
Does the policy include a
commitment to prevent pollution?
Evidence of such a commitment may be seen in
the objectives and targets. This sub-element
may have to wait for subsequent surveillance
audits to verify.)
5
6
Does the policy include a
commitment to comply with
applicable legislation and regulations
and other requirements that the
organization subscribes to?
Does the policy include a mechanism
9
procedures, groups/departments assigned,
meetings, etc.) for setting and reviewing
7
environmental objectives and targets
Is the policy documented (in a written or
electronic form), implemented (all portions
are being used), maintained (changed in
9
accordance with top management decisions)
and communicated evidence [sufficient
sample size is to be taken] to let all employees
know the contents of the policy) to all
8
employees?
Is the policy available to the public?
9
(Not necessarily distributed or sent out.
Cannot be confidential or interoffice memo or
letter.)
Mechanism is there through
pollution prevention, continual
improvement, regulatory
compliance.
Policy was approved by the County
Commission May 15, 2001 and is
communicated to all fenceline
employees
Policy is posted in public areas. Will
be posted on Jeffco Website.
C
C
O
Planning
Environmental Aspects
1
This section corresponds with
element 4.3.1 of ISO 14001
Is there a documented and maintained
9
C
F-44
SAMPLE DOCUMENTATION
procedure to identify the controllable
(controlled by the organization’s own actions)
aspects that the organization can most
likely influence? e.g.: Activity – handling
of hazardous materials; Aspect – potential for
accidental spillage; Product – Product “X”;
Aspect – a reformulation of the product to
reduce it volume; Service – vehicle
maintenance; Aspect – exhaust emissions.
Some organizations may identify only those
aspects requiring permits. Those are not,
necessarily, the only aspects at the facility.
Asking questions about life cycle effects and
interrelationship with the community may add
other aspects.) The purpose of these
9
As changes occur in operations,
EMS Team will evaluate associated
environmental aspects.
C
Add language to Section V.B. of SPEA explaining aspects rating
process.
O
9
On schedule but hasn’t come up yet.
C
9
Add summary of legal & other
requirements to Sec. IV of SP-LOR.
Limit scope for SP-LOR to
fenceline. Define “Other
Requirements” in Sec. III of SPLOR. Add to LOR Summary a
brief description of what the
requirement is. Add statement to
SP-LOR that we will identify legal
requirements as operations change.
O
procedures is to determine those
aspects that have present or can have
potential significant environmental
impacts (e.g.: Activity [above] – Impact –
contamination of soil or water; Product
[above] – Impact conservation of natural
resources; Services [above] – Impact reduction
of air pollution.)
9
The aspects associated with the
identified significant impacts are to be
considered when setting the
objectives.
(To show that the procedure is effective and
implemented, the identified aspects and
significant impacts are to be compared to the
procedure. Review the methodology of
significance and compare it with those impacts
that were not chosen to be significant.)
2
Is there evidence of updating of the
environmental aspects?
(Is there a mechanism to update? This will be
better audited with subsequent audits.)
Legal & Other Requirements
1
This section corresponds with
element 4.3.1 of ISO 14001
Is there a procedure for the
organization to identify and have
access (access refers to availability in an
understandable form to the individual who will
maintain compliance) to all legal and
other requirements (includes Federal,
state, and local laws, permits, licenses, etc.:
water, solid, air, noise, etc.) that they
subscribe to that are applicable to
their aspects?
(e.g. Activity [above] handling of hazardous
waste regulations; Product [above] – labeling
regulations; or Services [above] – automobile
emission standards/requirements.)
2
Is there a procedure/mechanism for
the organization to secure the latest
revisions of those requirements
identified above?
9
C
F-45
SAMPLE DOCUMENTATION
(If electronic on-line database, then latest
revision probably exists, if hard copy, evidence
is needed to be certain that any changes to
regulations are received.)
Objectives and Targets
1
This section corresponds with
element 4.3.3 of ISO 14001
Has the organization established and
maintained documented objectives
(e.g. increase metal recycling) and
targets (e.g. increase metal recycling
by 20% by 4/02) at each relevant (a
point in the organization where there
is an environmental impact) function
(e.g. department, building, plant,
group, etc.) and level (e.g.
maintenance manager and four floor
personnel) within the organization?
(Objectives and targets should be set
for all significant environmental
aspects.)
9
As baseline data becomes available,
quantify targets in percent or
dollars if possible.
Objectives & target data not
properly recorded for four facilities.
Data was available, but not in
proper format.
Minor
N
(Objectives and targets may be in
different documents. The overall
numbers may be in identified permits
or policies or plans but there needs to
be objectives and targets set for
relevant functions and levels of the
organization. This may also be in job
descriptions, goals of the
departments, etc.)
2
When establishing objectives, the
organization shall take into
consideration legal and other outside
requirements, technologies and
financial options, business and
operational considerations as well as
views of interested parties.
(Look for evidence of a methodology
or some analysis and be sure the
chosen objectives are consistent with
the methodology.)
9
C
Are the objectives and targets
consistent with the environmental
policy?
9
C
(Is there consistency between the
objectives/targets and the environmental
policy? Consistency does not mean that we
need to have objectives and targets for
commitments in the policy.)
Environmental Management
Programs
F-46
SAMPLE DOCUMENTATION
1
2
This section corresponds with
element 4.3.4 of ISO 14001
Does the program include the
designation of responsibilities at each
relevant function and level?
Does the program include a schedule
and the resources necessary to
achieve the objectives and targets?
9
9
C
Specify source of resources and
specify end dates where possible.
O
(The plan may be a developing plan with
changes and amendments as requires.)
Implementation and Operation
Structure and Responsibility
1
This section corresponds with
element 4.4.1 or ISO 14001
Are roles, responsibility and
authorities defined, documented, and
communicated?
9
C
9
C
9
C
9
C
(Can be in the form of an organization chart,
but does not have to be.)
2
NOTE: Be sure of sufficient sample
size of the evidence.
Has management provided the
necessary resources for this EMS?
(Resources include people, technology, money,
etc. The organization decides what and how
much of the resources are required. Evidence
of this may be in the environmental program –
4.3.4 of the standard.)
3
Has top management appointed an
environmental management
representative?
4
Are the roles of management
representative documented to include:
a. ensuring that the EMS
requirements established,
implemented and maintained
in accordance with ISO
14001;
b. reporting on the performance
of the EMS to top
management for review
management review – 4.6) and as
a basis for improvement of
the EMS?
Training, Awareness, &
Competency
(A team is acceptable.)
1
This section corresponds with
element 4.4.2 of ISO 14001
Have training needs been identified
9
Management Review scheduled for
early February
9
C
C
F-47
SAMPLE DOCUMENTATION
for those whose work has or can have
a significant environmental impact?
(These are individuals associated with
significant aspects.)
2.
Has the appropriate training been
performed?
3.
Are there procedures that are
documented and maintained to give
employees at the relevant functions
and level an awareness of the
following:
9
(evidence of training.)
Not complete at one facility.
Training has been scheduled for late
January and early February 2002.
9
Minor
N
C
(The employees to be considered here are to be
the same as those identified to be trained in
4.4.2 first paragraph. Being made aware the
consequences of a task is different than being
trained to perform the task.)
a.
b.
c.
the importance of
conformance with the
environmental policy and
procedures and with the
requirements of the EMS;
the significant environmental
impacts (actual or potential)
of their work and the
environmental benefits of
improved personal
performance;
their roles and
responsibilities in
conformance with the
environmental policy and
procedures and with the
requirements of the EMS;
and, (Including the emergency
preparedness and response
requirements as stated in 4.4.7 of
the standard.)
d.
the potential consequences
of not following the
specified operating
procedures and
responsibilities assigned to
them?
9
9
All employees surveyed know the
importance of conformance with the
Environmental Policy and
requirements of the EMS. All also
knew significant environmental
impacts of their work. A few (3) had
to be prompted.
C
C
9
C
9
C
(Evidence of the above being communicated to
the proper employees may be in the form of
training records or work instructions or some
other document. The evidence needs to show
that the employee was made aware of and
understood the above information. On the job
training may be accepted but evidence is still
required that the above was conveyed to the
specific employee. Asking random employees
to verify their knowledge and awareness of the
above points will also verify the effectiveness of
this element.)
4.
Has a determination of competency
based on education, training, or
9
C
F-48
SAMPLE DOCUMENTATION
5.
experience been made for personnel
performing tasks which can cause
significant environmental impacts?
Are all workers provided with
awareness training (including those not
associated with significant environmental
impacts) on the following:
a.
b.
c.
d.
the importance of
conformance with the
environmental policy and
procedures and with the
requirements of the EMS;
the environmental benefits of
improved personal
performance;
emergency preparedness and
response; and,
encouragement to look at
their own task (job) for
opportunities and things to
watch out for?
9
C
9
C
9
9
Emergency preparedness and
response training will be added to
New Employee Orientation.
Minor
N
C
NOTE: For all of the above, be sure
of a large enough sample size of
evidence.
Communication
1.
This section corresponds with
element 4.4.3 of ISO 14001
Are there procedures and records that
are maintained for the following types
of communications and activities
regarding the organization’s
environmental aspects and its overall
EMS: (both aspects and EMS)
a.
internal communications
between different levels (e.g.
managers to supervisors,
supervisors to line workers, etc.)
b.
and different functions; and,
the receiving (processing)
documenting (logging) and
responding (sending out answers)
to relevant (the organization
9
C
9
C
9
C
defines “relevant communication”)
communications from
external interested parties?
(Interested parties, such as,
community groups, government
agencies, individuals, etc.)
Environmental Management
System Documentation
1
This section corresponds with
element 4.4.4 of ISO 14001
Is the EMS documented?
9
Manual is in place
(Document is to provide a general description.
F-49
C
SAMPLE DOCUMENTATION
The EMS Manual, if it exists, can satisfy this.)
2
3
Does the documentation include the
core elements of this standard?
Does the documentation address the
interaction (organizationally and in the flow
of information) of the different parts of
the system?
9
Specified in System Procedures
C
9
Through references to related
documents.
C
9
Through System Procedure and
Operating Procedure elements
C
(e.g., How is information on new regulatory
requirements or changes to operational
procedures transmitted to individuals that need
to know?)
4.
Does the documentation point to
supporting systems?
(Does the system document how the related
information [regulations, permits, forms, etc.]
is to be used?)
Document Control
This section corresponds with
element 4.4.5 of ISO 14001
(There may be different methods and different
people for different types of documents but the
constraints must be specified.)
1
Are there procedures for controlling
all documents required by this
standard?
9
C
(Include all documents that are referred to in
this standard such as policy and procedures
and documentation.)
2
3.
Are the documents accessible?
(This may include accessibility on a network or
similar database.)
Are the documents periodically (the
organization must state the period but the
words “as needed” are not acceptable)
reviewed (evidence of review is required),
revised (in a controlled manner), and
approved (evidence required) for
9
In paper form and electronic
C
9
C
9
C
9
C
adequacy by authorized personnel?
(“Authorized” must be clear in a documented
format or obvious from organization structure
of some other means.)
4
Are the latest versions of the
appropriate documents available (can
be from an electronic database) in areas
where personnel perform tasks
essential to the effective functioning
of the EMS?
(e.g., The one who monitors an effluent stream
needs the procedure and form for taking the
sample and recording the results and the
administrator of the program needs to have
regulatory requirements available, although it
may be on an electronic database.)
5
Are obsolete documents removed
from use of otherwise protected
against unintended use?
F-50
SAMPLE DOCUMENTATION
6
7
Are those obsolete documents that are
retained for legal or knowledge
reasons clearly identified?
Are documents dated (the standard
actually requires dating) with the latest
revision, kept orderly, legible and
retained, is necessary, for a specified
period?
9
Stamped “Obsolete”
C
9
C
9
C
(Organization must state the retention period.)
8
1
2
3
4
5
1
Are there procedures that define the
“who and how” of creating or
modifying documents?
Operational Control
This section corresponds with
element 4.4.6 of ISO 14001
Have operational controls been
developed for operations and
activities associated with significant
environmental aspects?
(The significant aspects were derived from an
analysis of operations and activities.)
Does the maintenance plan (if one exists)
ensure that operational controls
remain in operation?
Have procedures been established and
been maintained to cover situations
when operational controls fail?
Are operating criteria (e.g.
temperature, pressure, flow) clearly
established and documented for
operations controls?
Have procedures and requirements
related to significant aspects of goods
and services been developed and
communication to suppliers and
contractors?
Emergency Preparedness and
Response
This section corresponds with
element 4.4.7 of ISO 14001
Are there maintained procedures to
identify potential for accidents and
emergency situations?
9 9
9
9
Operating Procedure for ink use not
in place, all others are in place.
Minor
N
No PPE on hand at one facility (on
order), all others are in place.
Minor
N
Computerized maintenance
programs are used except at 2121
Bldg.
C
9
C
9
C
9
On PACA website.
9
C
C
(Emergency situations may be obvious or may
not be in certain facilities. Emergencies may
not exist in all situations but accidents can
always happen. “Potential” can be
ascertained by an analytical evaluation or a
subjective one, but some evidence of evaluation
is required.)
2
Are there maintained procedures to
respond to accidents and emergency
situations and to prevent and
minimize the environmental impacts
9 9
Emergency phone numbers not
posted in Greenhouse.
F-51
C
O
SAMPLE DOCUMENTATION
3
that may be associated with them?
Are there reviews and revisions
(specifying frequently is not required) of the
emergency preparedness and response
procedures, particularly after an
incident?
9
C
(After an incident, there will be evidence of a
review of the procedures.)
4
Are there periodic tests of the above
procedures?
9
Some have been tested, others are
scheduled.
O
(Tests may not be practical in all types of
emergencies. Some tests may be simulations.)
Checking and Corrective Action
Monitoring and Measurement
1
This section corresponds with
element 4.5.1 of ISO 14001
Are there documented and maintained
procedures to monitor and measure,
on a regular (specified by the organization)
basis, the key (to be determined by the
9
C
organization but to be logically based)
characteristics (variables such as
temperature, pH, flow, % of contaminant, etc.)
of its operations (e.g. process type tasks)
and activities (e.g. testing and inspecting
type tasks) that can have a significant
2
3
1
impact on the environment?
Is there a calibration system for
monitoring equipment?
Does the organization maintain a
documented procedure for
periodically (the organization decides on the
frequency) evaluating compliance with
relevant environmental legislation and
regulations?
Non-Conformance and Corrective
and Preventative Action
This section corresponds with
element 4.5.2 of ISO 14001
Are there maintainable procedures for
defining responsibility and authority
for handling, investigating and taking
action to minimize impacts of
nonconformances?
9
Storage tanks, Freon Leak Detectors
C
9
Quarterly
C
9
C
9
C
(Nonconformances are findings that are
contrary to this standard or contrary to the
organization’s own procedures. It is possible
that a noncompliance to regulatory
requirements may also indicate nonconformity
to ISO 14001 or to the organization’s
procedures.)
2
Are there maintainable procedures for
F-52
SAMPLE DOCUMENTATION
3
4
1
initiating and completing corrective
and preventive action?
Are the corrective and preventive
actions taken appropriate to the
magnitude of the problems and
commensurate with the environmental
impact found? (This is a judgment call.)
Are the results of the corrective and
preventive actions implemented and
recorded?
Records
This section corresponds with
element 4.5.3 of ISO 14001
Are there maintainable procedures for
the identification, maintenance, and
disposition of environmental records?
These records shall include (the
9
9
C
Will be recorded when
implemented.
C
9
C
9
C
standard does not exclude other records to be
identified as “Environmental Records”)
training (4.4.2), records and the results
of audits (4.5.4) and reviews (4.6).
(Records that are not specifically identified as
“Environmental Records” but are part of the
EMS still must follow the guidelines of 4.4.4
and 4.4.5 of the standard.)
2
3
4
5
Are the records legible, identifiable
and traceable to the activity, product
or service involved?
Are the records stored and maintained
such that they are readily retrievable
and protected against damage,
deterioration or loss?
Are there documented specified
retention times for all of the records
identified?
Are the records maintained in a
manner to demonstrate accordance
with the standard and appropriate to
the system and the organization?
9
Paper and electronic copies.
C
9
C
9
C
9
C
(e.g., Are the records consistent with the intent
and content of this standard and yet
appropriate for the size and type of
organization?)
Environmental Management
System Audit
This section corresponds with
element 4.5.4 of ISO 14001
(The standard does not refer to this sub-element
as “an internal audit”. Therefore, it does not
have to be performed by employees of the
organization.)
1
Is there a maintainable procedure or
procedures for periodic (organization
decides frequency) EMS audits?
F-53
SAMPLE DOCUMENTATION
(The audits must be EMS audits, not
compliance type audits. It is possible and
acceptable to have compliance audits as part of
the EMS audits.)
2
Does the procedure for EMS audits
include:
a. the scope of the audit (the
standard states that the plan and
schedule shall be based upon
environmental importance of a
particular activity and the results of
the previous audits);
b.
c.
d.
frequency;
methodologies used (check
lists, etc.);
responsibilities (Auditors must
be properly qualified per 4.4.2 to
perform EMS audits.);
e.
f.
requirements; and,
reporting results? (To whom,
9
C
9
9
C
C
9
C
9
9
C
C
in what form, timeliness.)
(The standard does not address independence
of the auditor of the area audited. The
registrar will expect independence enough to
assure credibility by the auditor. This is a
judgment call by the registrar’s auditor.)
3
Does the EMS audit determine
whether the EMS has been
implemented and maintained and
conforms to this standard?
9
C
9
C
(Is there an overall assessment of the
organization’s EMS?)
4
1
2
Does the EMS audit provide results of
the audits to management? (for 4.6)
Management Review
This section corresponds with
element 4.6 of ISO 14001
Has the top management performed a
documented review of the EMS on a
periodic (frequency is chosen by the
organization) basis?
Does the review address:
a. the system’s continued
suitability;
b. the system’s adequacy
c. the system’s effectiveness
d. the system’s possible need to
change its policy;
e. the system’s possible need to
change its objectives and
other elements of the EMS in
light of the audit results,
continual improvement, etc.;
and,
f. the system audit as required
in 4.5.4?
9
First Management Review is
scheduled for early February 2002
O
Review not yet conducted.
O
F-54
SAMPLE DOCUMENTATION
Management Review
Sample Management Review Procedure – Port of Houston Authority, Houston, TX
Sample Management Review Quarterly Report – Jefferson County, AL
F-55
SAMPLE DOCUMENTATION
Procedure No 4.5.15
Effective Date: 1/23/02
Revision No. : 0
Prepared by: EAD
Reviewed By: EMS Core Team
Approved By: Wade Battles
Signature & Date:
1.0
2.0
Policy Reference:
‰
Provide and promote proactive environmental leadership and compliance in all business
decisions, pollution prevention, best management practices and policy programs, while
attaining the widest range of beneficial uses for the environment.
‰
Continually evaluate and improve activities and practices to achieve our established goals of
meeting and/or exceeding all current Federal and State standards and regulations.
Purpose
The purpose of this procedure is to document and develop a primary agenda of issues to be included
in the Senior Management Review meeting for evaluating the status of the PHA’s EMS.
3.0
Scope
This procedure applies to all Management Review meetings conducted at the PHA.
4.0
Responsibility & Authority
4.1
Senior Management
‰
4.2
Director of Protection Services, Facilities, and Operations, and the Container Terminals
Manager
‰
4.3
Attend Senior Management Review meetings and assist the Environmental Affairs
Manager with discussion.
EMS Core Team
‰
4.5
Attend Senior Management Review meetings, and provide feedback to the
Environmental Affairs Manager and the EMS Core Team.
EMS Champions
‰
4.4
Attend Senior Management Review meetings and provide feedback to the
Environmental Affairs Manager and the EMS Core Team.
Develop Agenda for the Senior Management Review meeting
Environmental Affairs Manager
F-56
SAMPLE DOCUMENTATION
5.0
‰
Scheduling and conducting semi-annual management review meetings during each 12month period.
‰
Ensuring all necessary data and other information are collected prior to the meeting.
Procedure
The Senior Management Review process is intended to provide a forum for reviewing and/or
improving the PHA’s EMS on a semi-annual basis, and to provide management with a vehicle for
making any changes to the EMS necessary to achieve its goals.
5.1
6.0
At a minimum, each Senior Management Review meeting will consider the following:
‰
Suitability, adequacy, and effectiveness, of the environmental policy
‰
Suitability, adequacy, and effectiveness of the PHA’s Objectives and Targets and the
status thereof;
‰
Suitability, adequacy, and effectiveness of the PHA Environmental Management Plan
and Performance Indicators
‰
Suitability, adequacy, and effectiveness of corrective and preventative action plans;
‰
Suitability, adequacy, and effectiveness of any EMS audits conducted since the last
Senior Management Review meeting
‰
Suitability, adequacy and effectiveness of training efforts; and,
‰
Results of any action items from the previous Senior Management Review meeting.
‰
Providing direction for changes needed to the EMS.
5.1
Meeting minutes will be generated by the Environmental Affairs Department and will include,
at a minimum the list of attendees, a summary of key issues discussed and any actions items
arising from the meeting.
5.2
A copy of the meeting minutes will be distributed to attendees and any individuals assigned
action item. A copy of the meeting minutes will be retained on file in the Environmental
Affairs Department.
Related Documents
4.2.1
4.3.13-14
4.4.11
4.5.11
Environmental Policy
Objectives and TargetsEnvironmental Management Plan
Training, Competency and Awareness
Corrective Action Procedure
F-57
SAMPLE DOCUMENTATION
EMS - Management
Review
Including Quarterly Report to
Management
02/13/2002
7:30 AM
General Services
Conference Room
Birmingham, AL 35203
Presented by: Bill Peters, EMR
Reference:
ISO 14001, Section 4.6 requires the following:
The organization’s top management shall, at intervals that it determines, review the Environmental
Management System (EMS), to ensure its continuing suitability, adequacy and effectiveness. The
management review process shall ensure that the necessary information is collected to allow
management to carry out this evaluation. This review shall be documented.
The Management Review shall address the possible need for changes to policy, objectives, and
other elements of the Environmental Management System, in the light of Environmental
Management System audit results, changing circumstances, and the commitment to continual
improvement.
I.
INTRODUCTION
The semi-annual review of our EMS by top management is an important component for ensuring
that we keep our commitment to continual improvement and for ensuring that the EMS is effective
in meeting our needs over time.
II.
SCOPE
The management review process is intended to provide a forum for discussion and improvement of
the EMS and to provide top management with a vehicle for making any changes needed to the
EMS.
III
REVIEW OF INTERNAL AUDIT RESULTS (Attached)
The Internal Audit conducted January 21-23 evaluated the conformance of the Jeffco EMS to the
requirements of ISO 14001. There were no major findings. However, five minor findings and five
observations, or suggestions for improvement, were documented.
This is the first in a continuing series of internal audits. Therefore, there were no outstanding
Preventive or Corrective Action Notices (PAN/CAN) to be evaluated during this audit.
The audit results reflect an ongoing need for management to emphasize that ISO 14001
conformance requires daily adherence to all our EMS procedures. ISO conformance depends on
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SAMPLE DOCUMENTATION
each individual employee and all levels of management understanding their roles and
responsibilities and working to implement and maintain the environmental management system.
All areas audited displayed competency and professionalism.
IV
REGULATORY ASSESSMENT REPORTS (Attached)
There are no known noncompliance issues related to the EMS at this time.
V
REVIEW OF OBJECTIVES AND TARGETS AND RELATED SIGNIFICANT ASPECTS
(Attached)
VI
INTERESTED PARTY ISSUES
The Environmental Protection Agency (EPA) has announced its intention to select and provide
technical assistance for up to five existing not-for-profit organizations in order to increase their
capacity to assist public entities wishing to adopt environmental management systems (EMS). The
assistance provided to these organizations will include help with developing business plans,
providing EMS education materials, train-the-trainer work sessions on ways to address the needs
of public agencies, and other marketing services. These five Local Resource Centers will be tied
to the National Public Entity Environmental Resource (PEER) Center.
Jefferson County has applied to be designated as one of the Local Resource Centers. If selected,
we will partner with the Environmental Management Department at Samford University and with
the Birmingham Chamber of Commerce.
VII
REVIEW OF THE ENVIRONMENTAL POLICY
The Jefferson County General Services and Fleet Management Departments are dedicated to best
management practices in the allocation of public resources for the benefit of its citizens with an
ongoing commitment to continual environmental improvement through employee training,
prevention of pollution, and full compliance with all appropriate legal and other requirements.
VIII
ENVIRONMENTAL MONITORING AND MEASUREMENT DATA
Monitoring and measurement data are maintained for the following:
•
•
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Fuel Tanks – No reported monitoring or measurement errors
Freon Leak Detectors – No reported monitoring or measurement errors
CONTINUING SUITABILITY OF THE EMS IN RELATION TO CHANGING
CONDITIONS AND INFORMATION
•
•
New or Modified Laws and Regulations
Training Needs and Status of Training Requirements
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SAMPLE DOCUMENTATION
•
•
Technology Improvements
Changes in Key Suppliers
Attachments:
• Nonconformance & Observation Report
• Regulatory Assessment Reports
• Progress Report of Objectives and Targets
• Positive Comments
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