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**DOE G 450.1-2**

**DRAFT XX-XX-04**

**Implementation Guide for Integrating Environmental Management Systems
into Integrated Safety Management Systems**

*\[This Guide describes suggested nonmandatory approaches for meeting
requirements. Guides [are not]{.underline} requirements documents and
[are not]{.underline} to be construed as requirements in any audit or
appraisal for compliance with the parent Policy, Order, Notice, or
Manual.\]*

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**U.S. Department of Energy**

**Washington, D.C. 20585**

PREFACE

DOE G 450.1-2*, Implementation Guide for Integrating Environmental
Management Systems into Integrated Safety Management Systems* is the
second guidance document in a series of Guides issued to provide
suggested approaches for meeting the requirements of DOE O 450.1. DOE
O 450.1 requires DOE elements to establish an Environmental Management
System (EMS) that is integrated into DOE's Integrated Safety Management
System (ISMS). Draft DOE G 450.1-1, which was issued for "review and
use" in October 2003, provides an overview of the integration process.
DOE G 450.1-2 provides detailed guidance relating to integrating EMSs
into a site's ISMS.

**CONTENTS**

Acronyms and Abbreviations ix

Introduction 1

Purpose 1

Applicability and Scope 1

Use of Guidance 1

Overview 1

CHAPTER I. Phase I---Planning and Aspects Identification

Step 1 Identifying Environmental Aspects I-1

1.1 TASK 1: Identify and List the Organization's Activities, Products,
and Services and Their Interactions With the Environment (Environmental
Aspects) I-1

1.1.1 Starting Task 1 I-2

1.1.2 Environmental Aspects Identification I-2

1.1.3 Approaches for Identifying Activities, Products, and Services and
their Interactions with the Environment I-3

1.2 TASK 2: Identify How Each Environmental Aspect Impacts the
Environment I-6

1.2.1 Understanding the Aspect Impact Analysis I-6

1.2.2 Approach to Characterizing Environmental Impacts I-6

1.2.3 Documenting Positive Impacts I-7

Step 2 Determining Significant Aspects I-8

2.1 TASK 3: Identify All Environmental Aspects That Are Regulated, Have
Regulatory Implications, or Are Required by DOE Directive I-8

2.1.1 Identifying Environmental Aspects with Regulatory Consequences
I-10

2.1.2 Specific Environmental Interactions I-11

2.1.3 Pollution Prevention I-13

2.1.4 Clean Air Act General Conformity I-13

2.1.5 Watershed Approach for Surface-Water Protection I-14

2.1.6 Site-Wide Approach for Groundwater Protection I-14

2.1.7 Natural Resources---Biota I-16

2.1.8 Wildland Fire Management Program I-17

2.1.9 Cultural Resources Management I-17

2.1.10 Long-Term Stewardship Program I-17

2.1.11 Preoperational Characterization and Assessment; Effluent and
Surveillance Monitoring I-18

2.1.12 Environmental Quality Systems I-20

**CONTENTS (continued)**

2.2 TASK 4: Determine Significance Based on Environmental and
Organizational Consideration I-22

2.2.1 "Significance" in the NEPA and ISMS/EMS Context I-22

2.2.2 Criteria for Scoring Likelihood of Occurrence I-23

2.2.3 Criteria for Scoring Environmental Consequences of Impacts I-24

2.2.4 Criteria for Scoring Mission Consequences I-24

2.2.5 Determination of Overall Impact Score I-26

Step 3 Setting Objectives and Targets I-28

3.1 TASK 5: Develop Objectives and Targets To Address Significant
Aspects I-28

3.1.1 Defining Objectives and Targets I-29

3.1.2 Approach to Setting Objectives and Targets I-30

3.2 TASK 6: Formalize Environmental Objectives and Targets And Develop
The Environmental Management Plan I-31

CHAPTER II. Phase II---Implementation and Operation

Step 4 Integrated Safety Management System/Environmental Management
System Documentation II-1

4.1 TASK 7: Updating the Integrated Safety Management
System/Environmental Management System Description II-1

4.1.1 Background II-2

4.1.2 Documenting Environmental Management System Elements II-2

4.2 TASK 8: Developing an Environmental Management System Roadmap II-2

4.2.1 Background II-2

4.2.2 EMS Roadmap Template II-3

Step 5 Developing Environmental Management Programs II-3

5.1 TASK 9: Create environmental management programs II-3

5.1.1 Create Environmental Management Programs II-4

5.2 TASK 10: Document Environmental Management Programs II-5

5.3 TASK 11: Approve the Environmental Management Programs II-5

5.3.1 Review and Approval II-6

5.3.2 Placement of Completed Environmental Management Program Documents
II-6

**CONTENTS (continued)**

Step 6 Developing Operational Controls II-6

6.1 TASK 12: Specify Operational controls II-6

6.1.1 Specifying Operational Controls II-7

6.2 TASK 13: Approve operational controls II-8

6.2.1 Review and Approval II-8

6.2.2 Placement of Completed Operational Controls II-8

Step 7 Develop Integrated Safety Management System/Environmental
Management System Procedures II-9

7.1 TASK 14: Establish Integrated Safety Management System/
Environmental Management System Procedures II-9

7.1.1 Integrated Safety Management System/Environmental Management
System Procedures II-11

7.1.2 The Role of Integrated Safety Management System/Environmental
Management System Procedures II-11

7.1.3 Keeping Procedures Simple II-11

7.2 TASK 15: Documenting Integrated Safety Management
System/Environmental Management System Procedures II-11

7.2.1 Integrated Safety Management System /Environmental Management
System Procedures II-11

7.2.2 Implementing Integrated Safety Management System/Environmental
Management System Procedures II-12

7.3 TASK 16: Approve Integrated Safety Management System/ Environmental
Management System procedures II-12

7.3.1 Review and Approval II-13

7.4 TASK 17: Implement Integrated Safety Management System/
Environmental Management System procedures II-13

7.4.1 Background II-13

7.4.2 Training II-13

7.4.3 Responsibility for Maintaining Records II-14

7.4.4 Maintaining Procedures II-14

7.4.5 Accessibility II-14

CHAPTER III. Phase III---Checking and Corrective Action

Step 8 Establish the ISMS/EMS Assessment Program III-1

8.1 TASK 18: Establish the ISMS/EMS Assessment Program III-1

**CONTENTS (continued)**

8.1.1 Background and Purpose III-2

8.1.2 The Assessment Program III-2

8.1.3 Assessment Concepts III-3

8.2 TASK 19: Plan the Assessment III-5

8.2.1 Basic Principles III-6

8.2.2 Conducting the Assessment III-7

8.3 TASK 20: Conduct Onsite Assessment Activities III-7

CHAPTER IV. Phase IV---Management Review and System Maintenance

Step 9 Develop the management review process IV-1

9.1 TASK 21: Prepare for the Management Review IV-1

9.1.1 Background IV-2

9.1.2 Importance of Senior Management Involvement in the Management
Review IV-3

9.1.3 Coordinating the Management Review IV-3

9.1.4 Management Review Participants IV-4

9.2 TASK 22: Conduct the Management Review IV-4

9.2.1 Background IV-4

9.2.2 Decisions Made in the Management Review IV-6

9.2.3 Documenting the Management Review IV-7

9.2.4 Followup to the Management Review IV-7

Step 10 Develop a Plan to Keep the ISMS/EMS Updated IV-8

10.1 TASK 23: Keeping the ISMS/EMS Updated IV-8

10.1.1 Background IV-8

10.1.2 Environmental Aspects IV-9

10.1.3 Legal and Other Requirements IV-9

10.1.4 Objectives and Targets IV-9

10.1.5 Environmental Management Programs IV-10

10.1.6 Training IV-10

10.1.7 Operational Controls IV-10

10.1.8 Resources for the Environmental Management System IV-11

10.1.9 Occurrence Identification and Corrective Actions IV-11

10.1.10 Developing a Formal Maintenance Schedule IV-11

**Appendixes**

A. Additional Guidance Documents

B. EMS Roadmap Templates

C. Assessments

D. Glossary

E. References

**TABLES**

1\. Example of Listing Environmental Aspects and
Activities/Products/Services I-5

2\. Example of Listing Environmental Impacts I-7

3\. Regulatory and Other Requirements Related to Environmental Aspects
I-10

4\. Assigning a Regulatory Score to aspects I-12

5\. Sample criteria for scoring the likelihood of occurrence I-23

6\. Sample Criteria for Scoring Environmental Consequences on DOE Sites
I-25

7\. Sample Criteria for Scoring Mission Consequences for DOE Sites I-25

8\. Determination of Significance Based on Environmental and
Organizational Considerations I-27

8a. Rank of Overall Significance Based on environmental and
Organizational Considerations I-28

9\. Overview of Objectives, Targets, Required Resources, and Management
Approval Status I-32

10\. Sample portion of the assessment questionnaire III-13

11\. Sample ISMS/EMS Corrective Action Report Template III-15

12\. Example. Suggested schedule for maintaining and Updating Required
and Important Selected Elements of the ISMS/EMS. IV-13

**FIGURES**

1\. Sample assessment program reflecting how concepts of the
plan-do-check-act cycle are incorporated in it III-4

2\. ISMS/EMS assessment process flow chart III-8

3\. Identifying legal and other requirements and new activities,
products, and services that are incorporated into the ISMS/EMS IV-14

Acronyms and Abbreviations

ANSI American National Standards Institute

ASER Annual Site Environmental Reports

ASQC American Society for Quality Control

CAR Corrective Action Report

CCE continuing core expectation

CERCLA Comprehensive Environmental Response, Compensation and Liability
Act

CRD Contractor Requirements Document

CRMP Cultural Resources Management Plan

D & D Decontamination and Decommissioning

DOE U.S. Department of Energy

EIS Environmental Impact Statement

EMP environmental management program

EPA U.S. Environmental Protection Agency

EMS Environmental Management System

ES&H Environment, Safety and Health

ISMS Integrated Safety Management System

ISO International Standards Organization

LTS long-term stewardship

MSDS material safety data sheets

NAAQS national ambient air quality standards

NEPA National Environmental Policy Act

NNSA National Nuclear Security Administration

ODS ozone-depleting substance

QA quality assurance

QC quality control

QMP Quality Management Plan

QS Quality System

UFP-QAPP Uniform Federal Policy for Quality Assurance Project Plan

UFP-QS Uniform Federal Policy for Implementing Environmental Quality
Systems

UST underground storage tank

Introduction

Purpose

This document provides discretionary guidance for implementing the
requirements of Department of Energy (DOE) Order (O) 450.1,
*Environmental Protection Program*. DOE O 450.1 requires implementation
of sound stewardship practices that are protective of the air, water,
land, cultural and ecological resources impacted by DOE operations, and
by which DOE meets or exceeds compliance with applicable environmental,
public health and resource protection laws, regulations and DOE
requirements in a cost-effective way. This objective is to be
accomplished by implementing Environmental Management Systems (EMSs) as
part of existing Integrated Safety Management Systems (ISMSs)
established pursuant to DOE P 450.4, *Safety Management System Policy*,
at DOE facilities. This Guide provides suggested approaches for meeting
the requirements of DOE O 450.1.

Applicability and Scope

This Guide is for use by all DOE elements, including the National
Nuclear Security Administration (NNSA) and contractors required to
implement DOE O 450.1.

Use of Guidance

DOE Guides are not requirements documents and may not be construed as
requirements in any audit or assessment of compliance with the
associated Policy, Order, Notice, or Manual. The information in this
Guide will be useful for the implementation of DOE O 450.1,
*Environmental Protection Program*. This Guide provides information on
acceptable methods for meeting the requirements of DOE O 450.1.
Alternatively, other methods that are equally effective in meeting
desired levels of environmental protection and that satisfy the
requirements of DOE O 450.1 may be used.

Overview

DOE O 450.1 requires DOE elements to establish an EMS that is integrated
into a DOE site's ISMS. The integration of an EMS into a ISMS
(hereinafter referred to as ISMS/EMS) provides a unified strategy for
the management of resources; the control and attenuation of risks; and
the establishment and achievement of the organization's environment,
safety and health goals. The ISMS/EMS should be viewed as an enhancement
of ISMS that adds those EMS elements not previously included in the
ISMS. The guidance contained in this document recognizes that many DOE
sites have already implemented ISMSs and should, therefore, have most if
not all of the elements of an EMS already in place. This document
focuses on providing guidance to assist DOE sites in identifying those
missing EMS elements and integrating them into the site's ISMS.

This Guide is organized around the following four phases of establishing
an EMS:

-   Phase I, Planning and Aspects Identification;

-   Phase II, Implementation and Operation;

-   Phase III, Checking and Corrective Action; and

-   Phase IV, Management Review and System Maintenance.

Chapter I, *Phase I---Planning and Aspects Identification,* provides
guidance on how to identify environmental aspects associated with site
activities, products and services, and determine the significance of
impacts associated with these aspects. Chapter II---*Phase II,
Implementation and Operation,* provides guidance on how to document an
EMS through the use of the site's ISMS description. Chapter II also
provides guidance on how to develop or modify existing environmental
management programs and how to develop operational controls and
procedures. Chapter III---*Phase III, Checking and Corrective Action,*
provides guidance on conducting an internal assessment program. Chapter
IV---*Phase IV,* *Management Review and System Maintenance,* provides
guidance on conducting a management review and ensuring that the
ISMS/EMS is current. The following matrix is a roadmap to the entire
ISMS/EMS integration process.

+----------+--------------+-------------------------------------------+
| # *      | **STEP**     | **TASK**                                  |
| *PHASE** |              |                                           |
+----------+--------------+-------------------------------------------+
| **I.     | 1\.          | 1\. Identify & List the Organization's    |
| Planning | Identifying  | Activities, Products & Services and Their |
| and      | E            | Interactions With the Environment         |
| Aspects  | nvironmental | (environmental aspects).                  |
| Identifi | Aspects      |                                           |
| cation** |              |                                           |
+----------+--------------+-------------------------------------------+
|          | 2\.          | 2\. Identify How Each Environmental       |
|          | Determining  | Aspect Impacts the Environment            |
|          | Significant  |                                           |
|          | Aspects      |                                           |
+----------+--------------+-------------------------------------------+
|          |              | 3.Identify Environmental Aspects that are |
|          |              | regulated, have regulatory implications,  |
|          |              | or are required by DOE directive          |
+----------+--------------+-------------------------------------------+
|          |              | 4\. Determination of Significance Based   |
|          |              | On Environmental and Organizational       |
|          |              | Considerations                            |
+----------+--------------+-------------------------------------------+
|          | 3\. Setting  | 5\. Develop objectives and targets to     |
|          | objectives   | address significant aspects               |
|          | and targets  |                                           |
+----------+--------------+-------------------------------------------+
|          |              | 6\. Formalize Environmental Objectives    |
|          |              | and Targets                               |
+----------+--------------+-------------------------------------------+
| **II.    | 4\.          | 7\. Updating the Integrated Safety        |
| Implem   | Integrated   | Management System/Environmental           |
| entation | Safety       | Management System Description             |
| and      | Management   |                                           |
| Ope      | System/E     |                                           |
| ration** | nvironmental |                                           |
|          | Management   |                                           |
|          | System       |                                           |
|          | D            |                                           |
|          | ocumentation |                                           |
+----------+--------------+-------------------------------------------+
|          |              | 8\. Developing an Environmental           |
|          |              | Management System Roadmap                 |
+----------+--------------+-------------------------------------------+
|          | 5\.          | 9\. Create Environmental Management       |
|          | Developing   | Programs                                  |
|          | E            |                                           |
|          | nvironmental | 10.Document Environmental Management      |
|          | Management   | Programs                                  |
|          | Programs     |                                           |
|          |              | 11.Approve Environmental Management       |
|          |              | Programs                                  |
+----------+--------------+-------------------------------------------+
|          | 6\.          | 12\. Specify Operational Controls         |
|          | Developing   |                                           |
|          | Operational  |                                           |
|          | Controls     |                                           |
+----------+--------------+-------------------------------------------+
|          | 7\. Develop  | 13\. Approve Operational Controls         |
|          | ISMS/EMS     |                                           |
|          | Procedures   | 14\. Establish ISMS/EMS Procedures        |
|          |              |                                           |
|          |              | 15\. Document ISMS/EMS Procedures         |
|          |              |                                           |
|          |              | 16\. Approve ISMS/EMS Procedures          |
|          |              |                                           |
|          |              | 17\. Implement ISMS/EMS Procedures        |
+----------+--------------+-------------------------------------------+
| **III.   | 8\.          | 18\. Establish the ISMS/EMS Assessment    |
| Checking | Establish    | Program                                   |
| and      | the ISMS/EMS |                                           |
| Co       | Assessment   | 19\. Plan the Assessment                  |
| rrective | Program      |                                           |
| Action** |              | 20\. Conduct Onsite Assessment Activities |
|          | 9\. Develop  |                                           |
|          | the          | 21\. Prepare for the Management Review    |
|          | Management   |                                           |
|          | Review       | 22\. Conduct the Management Review        |
|          | Process      |                                           |
+----------+--------------+-------------------------------------------+
| **IV.    | 10\. Develop | 23\. Keeping the ISMS/EMS Updated         |
| Ma       | a Plan to    |                                           |
| nagement | Keep the     |                                           |
| Review   | ISMS/EMS     |                                           |
| and      | Updated      |                                           |
| System   |              |                                           |
| Maint    |              |                                           |
| enance** |              |                                           |
+----------+--------------+-------------------------------------------+

#  Phase I---Planning and Aspects Identification

# Identifying Environmental Aspects {#identifying-environmental-aspects .H1}

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## TASK 1: Identify and List the Organization's Activities, Products, and Services and Their Interactions With the Environment (Environmental Aspects) {#task-1-identify-and-list-the-organizations-activities-products-and-services-and-their-interactions-with-the-environment-environmental-aspects .H2}

## References {#references .sub1}

## This task fulfills DOE Order requirements listed below. {#this-task-fulfills-doe-order-requirements-listed-below. .sub1}

-   The ISMS/EMS includes policies \[and\] procedures to identify
    activities with significant environmental impacts \[DOE O 450.1
    §4.a.(2)\].

-   The ISMS/EMS provides for the systematic planning of programs for
    public health and environmental protection \[DOE O 450.1
    §4.a.(1)(a)\].

-   The ISMS/EMS provides for the systematic planning of programs for
    pollution prevention \[DOE O 450.1 §4.a.(1)(b)\].

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element. .sub1}

-   ISMS Core Function 2, "Analyze the Hazards: Hazards associated with
    the work are identified, analyzed and categorized."

    1.  Starting Task 1

Task 1 in developing the ISMS/EMS is to identify how the organization
might impact the environment. In EMS terms, this is known as
*identifying the environmental aspects* of an organization's existing,
as well as new or proposed *activities, products, and services*. These
cover all the possibilities for an organization to influence the
environment, both positive and negative. Options to identify
environmental aspects are described below. To understand these
approaches, individuals must first have a working knowledge of the terms
*activities, products, and services* and *environmental aspects* and
know how they relate to a DOE site.

Activities

Activities offer the greatest possibilities for DOE sites to influence
the environment. Activities may include those that generate waste
(radioactive, hazardous, solid waste), such as construction of waste
management units or equipment maintenance, or general administrative
activities that use resources, including paper, water, or natural
resources.

Products

DOE sites do not, on the whole, make products in the conventional
manufacturing sense. The aspects identification methodology will,
therefore, place greater emphasis on activities and services typically
associated with DOE operations. However, policies and/or procedural
documents may have tangible environmental implications when sites
implement them. For example, the institutional control policy (DOE P
454.1, *Use of Institutional Controls*) provides a mechanism designed to
appropriately limit access to or uses of land, facilities and other real
and personal properties to protect cultural and natural resources, which
can have tangible environmental implications when put into practice.
These policies/procedures may therefore be considered products by
organizations that are determining their impacts on the environment.

Services

DOE sites may include several organizations that provide services to
other site operations. For example, services may include waste
treatment, waste pickup, and technical support services. These services
should be considered when determining how a site interacts with the
environment.

2.  Environmental Aspects Identification

Environmental aspects are the attributes of a site's activities,
products, and services that can interact with the environment. An
environmental aspect signifies the possibility of an environmental
impact, whether good or bad.

DOE sites that have implemented ISMS/EMSs have already identified their
various activities, products, and services. The process of identifying
activities, products, and services may be accomplished using a variety
of techniques. In small organizations, individuals may be able to name
all of the activities, products, and services at the site. This is
unlikely to be the case at the larger DOE sites, given their size and
complexity. Large DOE sites should conduct the analysis at the lowest
work activity level and then aggregate the data into the site-wide
analysis. Section 1.1.3 contains some commonly used approaches to
identify activities, products, and services within an organizational
unit.

Many parallels exist between safety management and environmental
management. For example, using a ladder in the workplace could result in
a worker injury. Therefore, a *possible* *fall* is the *safety hazard*
of a ladder in the workplace in the same way that a possible *spill* is
an *environmental aspect* of *waste transportation*. In other words, an
environmental aspect is the equivalent of a safety hazard.

3.  Approaches for Identifying Activities, Products, and Services and
    their Interactions with the Environment

This guidance describes three approaches that may be used to identify
activities, products, and services and can also be used to identify the
environmental aspects. In some cases, it may be possible to identify
activities, products, and services and their associated environmental
aspects at the same time to avoid duplication and increase efficiency.
In other cases, it is necessary to first identify all of the activities,
products, and services, and then determine what the environmental
aspects of these are. The three approaches are---

-   brainstorming,

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-   physical walk-through, and

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-   employee input.

Approach 1----Brainstorming

The site ISMS/EMS team (see Section 7 of draft DOE G 450.1-1 for a
discussion of how to establish a site ISMS/EMS team) and other
individuals with relevant knowledge participate in a brainstorming
session. Brainstorming is extremely effective when participants have a
detailed understanding of the site's activities, products, and services
and their environmental aspects. Typically an organization assembles an
ISMS/EMS team at the site. This group meets and lists all the activities
products and services that occur on the site. In many cases,
brainstorming can be supplemented and structured by using site documents
and records to direct the group. Common examples are regulatory
documents, National Environmental Policy Act (NEPA) documents,
compliance agreements, and the Annual Site Environmental Reports
(ASERs). Brainstorming may be inadequate by itself, so sites can use
additional approaches, such as the physical walk-through and employee
input for further exploration.

Approach 2----Physical Walk-Through

This technique involves an actual walk-through of all areas and
functions of the organization. Seeing these different areas and
operations serves as a visual trigger to identify possible interactions
with the environment. It is most effective to have the ISMS/EMS team
conduct the walk-through of all areas and operations of the site to
ensure that the analysis includes all possible sources. The team should
have a detailed understanding of the activities and operations in a
particular location. It should also be familiar with the potential
environmental issues of various operations and activities. It may be
useful to provide a checklist of potential environmental aspects that
may prompt the ISMS/EMS team to recognize such aspects. The Team can
develop these types of checklists in a brainstorming exercise, like that
described above. The walk-through should ensure the inspection and
consideration of all areas and operations. This effort requires
sufficient time for the completion of a thorough survey of the entire
site.

Approach 3----Employee Input

No other individuals are likely to be as familiar with a particular area
of the site as the employees who work there. It can be particularly
useful, therefore, to engage employees in the process of identifying
activities, products, and services that involve an environmental aspect.
An added benefit of soliciting employee input is that it begins the
process of raising employee awareness, involvement, and eventually
ownership of practices that avoid waste and environmental degradation.

To be useful, employee input needs to be structured, thus enabling its
proper evaluation. A questionnaire or survey instrument can be an
effective tool for capturing employee input. Following are examples of
appropriate questions to ask on a questionnaire.

-   Do activities in your work area---

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-   *use chemicals, radiological sources, or other hazardous
    substances?*

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-   *use appreciable amounts of materials or natural resources?*

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-   *discharge to air, soil, water, and/or sewers?*

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-   *produce solid waste (e.g., scrap, refuse)?*

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-   *consume large amounts of electrical energy or fuels?*

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-   *consume large amounts of water?*

    -   Is the site prepared for any accident or emergency?

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-   *Does the site have adequate training and/or experience to avoid,
    prevent, or mitigate potential environmental consequences?*

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-   *Are there activities that involve the use of material safety data
    sheets (MSDS)?*

-   *Do any other conditions or attributes of the
    activity/product/service pose a risk to the environment or to health
    and safety?*

Environmental aspects identified should be listed against the activity
with which they are associated (see Table 1). Table 1 provides some
examples of typical environmental aspects at DOE sites. These illustrate
how the environmental aspects are paired with the activities, products,
and services that cause them.

Table 1. Example of listing environmental aspects and
activities/products/services

+------------------------------------+---------------------------------+
| **ENVIRONMENTAL ASPECT**           | *                               |
|                                    | *Activities/products/services** |
+------------------------------------+---------------------------------+
| Air Emissions                      | -   Using and Storing Chemicals |
|                                    |                                 |
|                                    | -   Constructing or Modifying   |
|                                    |     Facilities, Processes, or   |
|                                    |     Equipment                   |
|                                    |                                 |
|                                    | -   Deactivating,               |
|                                    |     Decommissioning,            |
|                                    |     Dismantling or Closing      |
|                                    |     Facilities, Equipment, and  |
|                                    |     Processes                   |
|                                    |                                 |
|                                    | -   Maintaining, Servicing, or  |
|                                    |     Repairing Refrigeration and |
|                                    |     Air Conditioning Equipment  |
|                                    |                                 |
|                                    | -   Constructing Hazardous      |
|                                    |     Waste Units                 |
|                                    |                                 |
|                                    | -   Closing Waste Management    |
|                                    |     Units                       |
|                                    |                                 |
|                                    | -   Combusting fuel for heat,   |
|                                    |     power or electricity        |
+------------------------------------+---------------------------------+
| Disturbance of Cultural and        | -   Constructing or Modifying   |
| Historic Resources                 |     Facilities, Processes, or   |
|                                    |     Equipment                   |
|                                    |                                 |
|                                    | -   Conducting Open Burning     |
|                                    |                                 |
|                                    | -   Constructing or Modifying   |
|                                    |     Aboveground and Underground |
|                                    |     Storage Tanks (USTs)        |
+------------------------------------+---------------------------------+
| Releases to Wastewater System and  | -   Deactivating,               |
| Groundwater                        |     Decommissioning,            |
|                                    |     Dismantling, or Closing     |
|                                    |     Facilities, Equipment, and  |
|                                    |     Processes                   |
|                                    |                                 |
|                                    | -   Conducting Research and     |
|                                    |     Development                 |
|                                    |                                 |
|                                    | -   Leaks, Spills, and Releases |
|                                    |     from Waste Management       |
|                                    |     Activities                  |
|                                    |                                 |
|                                    | -   Closing Waste Management    |
|                                    |     Units                       |
+------------------------------------+---------------------------------+
| Medical Waste Generation,          | -   Conducting Research and     |
| Management, and Disposal           |     Development                 |
+------------------------------------+---------------------------------+
| Radioactive Waste Generation,      | -   Preparing Buildings or      |
| Management, and Disposal           |     Facilities for Transfer to  |
|                                    |     Surplus, Inactive Facility  |
|                                    |     Status or D & D             |
|                                    |                                 |
|                                    | -   Leaks, Spills, and Releases |
|                                    |     from Waste Management       |
|                                    |     Activities                  |
|                                    |                                 |
|                                    | -   Closing Waste Management    |
|                                    |     Units                       |
|                                    |                                 |
|                                    | -   Conducting Research and     |
|                                    |     Development                 |
|                                    |                                 |
|                                    | -   Disposition of Excess       |
|                                    |     Materials                   |
|                                    |                                 |
|                                    | -   Treating, Storing,          |
|                                    |     Disposing of Waste          |
|                                    |                                 |
|                                    | -   Cleanup of Legacy Waste     |
|                                    |     Sites                       |
+------------------------------------+---------------------------------+

## TASK 2: Identify How Each Environmental Aspect Impacts the Environment  {#task-2-identify-how-each-environmental-aspect-impacts-the-environment .H2}

## Reference {#reference .sub1}

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element.-1 .sub1}

-   ISMS Core Function 2, "Analyze the Hazards: Hazards associated with
    the work are identified, analyzed and categorized."

Task 2 involves the identification of the *potential* *environmental
impacts* of an environmental aspect. A potential environmental impact is
defined by its likelihood of occurrence and the likely consequences if
it does occur. When the potential environmental impacts have been
identified, their descriptions should be recorded alongside the activity
and aspect with which they are associated. To assist in the
identification of potential impacts, Table 2 lists some sample
environmental impacts. The environmental impact should include as much
detail as possible including the identification of pollutants.

1.  Understanding the Aspect Impact Analysis

Aspect impact analysis identifies the significant aspects (i.e.,
interactions with the environment) that site management should address
to prevent or control activities thereby reducing the site's risk to the
environment. There is no single correct approach to aspect
identification and impact analysis. Differences in structures and
missions will lead organizations to adopt different approaches. Whenever
possible, aspect impact analysis should rely on existing site
information from documents such as Environmental Impact Statements
(EISs), permit applications, ASERs, and ISMS documents.

2.  Approach to Characterizing Environmental Impacts

As discussed previously, the potential environmental impact of an aspect
is defined by the likelihood of that aspect occurring and the likely
consequences to the environment, mission, and/or community when it does
occur. Although it is possible to determine these characteristics in a
technically rigorous manner, including the use of decision trees,
modeling, and studies of toxicological parameters, this level of rigor
is rarely necessary and is often impractical for purposes of identifying
how an environmental aspect affects the environment. In most cases,
individuals with experience at a DOE site should be able to assign a
realistic likelihood and consequence to potential environmental impacts.
In many cases, sites can use the experiences of other organizations or
sites for similar activities under similar circumstances, and the
environmental aspects and impacts are likely to be comparable.
Quantification of potential environmental impacts, where possible, will
facilitate the determination of significance. Entries in the "impacts"
column of Table 2 should be as descriptive as possible; for example,
instead of simply listing a potential spill impact as "soil
contamination," it would be more useful to describe the impact as "soil
contamination----biohazards." This fuller description, when available,
will greatly facilitate the proper determination of the impact's
significance.

Table 2. Example of listing environmental impacts

+---------------------+-----------------------------+------------------+
| **ENVIRONMENTAL     | **Act                       | POTENTIAL        |
| ASPECT**            | ivities/products/services** | IMPACTS          |
+---------------------+-----------------------------+------------------+
| Air Emissions       | -   Using and Storing       | General          |
|                     |     Chemicals               | reduction in air |
|                     |                             | quality and      |
|                     | -   Constructing or         | potential human, |
|                     |     Modifying Facilities,   | ecological, and  |
|                     |     Processes, or Equipment | habitat effects  |
|                     |                             | in the locality  |
|                     | -   Deactivating,           | affecting all    |
|                     |     Decommissioning,        | media and biota. |
|                     |     Dismantling or Closing  |                  |
|                     |     Facilities, Equipment,  |                  |
|                     |     and Processes           |                  |
|                     |                             |                  |
|                     | -   Maintaining, Servicing, |                  |
|                     |     or Repairing            |                  |
|                     |     Refrigeration and Air   |                  |
|                     |     Conditioning Equipment  |                  |
|                     |                             |                  |
|                     | -   Constructing Hazardous  |                  |
|                     |     Waste Units             |                  |
|                     |                             |                  |
|                     | -   Closing Waste           |                  |
|                     |     Management Units        |                  |
|                     |                             |                  |
|                     | -   Combusting fuel for     |                  |
|                     |     heat, power, or         |                  |
|                     |     electricity             |                  |
+---------------------+-----------------------------+------------------+
| Disturbance of      | -   Constructing or         | Ecological       |
| Cultural and        |     Modifying Facilities,   | damage, damage   |
| Historic Resources  |     Processes, or Equipment | of culturally    |
|                     |                             | and historically |
|                     | -   Conducting Open Burning | significant      |
|                     |                             | artifacts.       |
|                     | -   Constructing or         |                  |
|                     |     Modifying Aboveground   |                  |
|                     |     and Underground Storage |                  |
|                     |     Tanks                   |                  |
+---------------------+-----------------------------+------------------+
| Releases to         | -   Deactivating,           | Runoff to local  |
| Wastewater System   |     Decommissioning,        | surface waters   |
| and Groundwater     |     Dismantling or Closing  | with species,    |
|                     |     Facilities, Equipment,  | habitat, biota,  |
|                     |     and Processes           | and fisheries    |
|                     |                             | impact. Leaching |
|                     | -   Conducting Research and | to groundwater   |
|                     |     Development             | aquifer of       |
|                     |                             | hazardous        |
|                     | -   Leaks, Spills, and      | wastes.          |
|                     |     Releases from Waste     |                  |
|                     |     Management Activities   |                  |
|                     |                             |                  |
|                     | -   Closing Waste           |                  |
|                     |     Management Units        |                  |
+---------------------+-----------------------------+------------------+
| Medical Waste       | -   Conducting Research and | Ecological       |
| Generation,         |     Development             | damage,          |
| Management, and     |                             | contamination of |
| Disposal            |                             | air, water, and  |
|                     |                             | soil with        |
|                     |                             | biohazards,      |
|                     |                             | impact to human  |
|                     |                             | health and       |
|                     |                             | biota, waste     |
|                     |                             | generation.      |
+---------------------+-----------------------------+------------------+
| Radioactive Waste   | -   Preparing Buildings or  | Ecological       |
| Generation,         |     Facilities for Transfer | damage,          |
| Management, and     |     to Surplus, Inactive    | contamination of |
| Disposal            |     Facility Status or D &  | air, water, and  |
|                     |     D                       | soil with        |
|                     |                             | radiological     |
|                     | -   Leaks, Spills, and      | contaminants,    |
|                     |     Releases from Waste     | impact to human  |
|                     |     Management Activities   | health and       |
|                     |                             | biota, waste     |
|                     | -   Closing Waste           | generation.      |
|                     |     Management Units        |                  |
|                     |                             |                  |
|                     | -   Conducting Research and |                  |
|                     |     Development             |                  |
|                     |                             |                  |
|                     | -   Disposing of Excess     |                  |
|                     |     Materials               |                  |
|                     |                             |                  |
|                     | -   Treating, Storing,      |                  |
|                     |     Disposing of Waste      |                  |
|                     |                             |                  |
|                     | -   Cleanup of Legacy Waste |                  |
|                     |     Sites                   |                  |
+---------------------+-----------------------------+------------------+

1.  Documenting Positive Impacts

For purposes of this Guide, an environmental impact is "any change to
the environment, whether adverse or beneficial, wholly or partially
resulting from an organization's activities, products, or services."
Although the aspect/impact analysis is inherently geared toward
identifying risks and, essentially, the degree of negative impact, it
can also identify those positive impacts on the environment that are a
result of existing programs or activities. Examples of positive impacts
include protecting wetlands with buffer strips and maintaining wooded
areas to protect species and habitat diversity. Positive impacts should
be identified in the aspect/impact analysis because the aspects that
create them may be incorporated into environmental management programs
(EMPs) and systematically managed.

As an example, a site may voluntarily decide to let a 50-foot buffer
strip grow alongside a stream. This action can have positive impacts on
the environment such as reduced storm-water flow, sediment loading, etc.
A proactive program may need ongoing management to maintain the buffer
strip.

When characterizing impacts as "positive," it is important that the
impact actually improve the quality of the environment and is not just
the result of minimizing a negative impact. For example, cleaning up a
site that has contaminated the soil is not a positive impact; it is
simply mitigating a negative impact (contamination).

# Determining Significant Aspects {#determining-significant-aspects .H1}

## TASK 3: Identify All Environmental Aspects That Are Regulated, Have Regulatory Implications, or Are Required by DOE Directive {#task-3-identify-all-environmental-aspects-that-are-regulated-have-regulatory-implications-or-are-required-by-doe-directive .H2}

## References {#references-1 .sub1}

## This task fulfills several DOE Order requirements listed below. {#this-task-fulfills-several-doe-order-requirements-listed-below. .sub1}

-   The ISMS/EMS provides for the systematic planning of programs for
    compliance with applicable requirements \[DOE O 450.1 §4.a.(1)(c)\].

-   The ISMS/EMS includes (if applicable) conformity of DOE proposed
    actions with State Implementation Plans to attain and maintain
    national ambient air quality standards \[DOE O 450.1 §4.b.(1)(a)\].

-   The ISMS/EMS includes (if applicable) implementation of a watershed
    approach for surface-water protection \[DOE O 450.1 §4.b.(1)(b)\].

-   The ISMS/EMS includes (if applicable) implementation of a sitewide
    approach for groundwater protection \[DOE O 450.1 §4.b.(1)(c)\].

-   The ISMS/EMS includes (if applicable) protection of other natural
    resources, including biota \[DOE O 450.1 §4.b.(1)(d)\].

-   The ISMS/EMS includes (if applicable) protection of site resources
    from wildland and operational fires \[DOE O 450.1 §4.b.(1)(e)\].

-   The ISMS/EMS includes (if applicable) protection of cultural
    resources \[DOE O 450.1 §4.b.(1)(f)\].

-   The ISMS/EMS promotes the long-term stewardship of a site's natural
    and cultural resources throughout its operational, closure, and
    postclosure life cycle \[DOE O 450.1 §4.b.(2)\].

-   The ISMS/EMS provides for reduction or elimination of the generation
    of waste, the release of pollutants to the environment, and the use
    of Class I ozone-depleting substances (ODS) through source
    reduction, reuse, segregation, and recycling and by procuring
    recycled-content materials and environmentally preferable products
    and services \[DOE O 450.1 §4.b.(3)\].

-   The ISMS/EMS ensures the early identification of, and appropriate
    response to, potential adverse environmental impacts associated with
    DOE operations, including, as appropriate, preoperational
    characterization and assessment and effluent and surveillance
    monitoring \[DOE O 450.1 §4.b.(4)\].

-   The ISMS/EMS includes environmental monitoring, as appropriate, to
    support the site's ISMS, to detect, characterize, and respond to
    releases from DOE activities; assess impacts and estimate dispersal
    patterns in the environment; characterize the pathways of exposure
    to members of the public; characterize the exposures and doses to
    individuals and to the population; and to evaluate the potential
    impacts to the biota in the vicinity of the DOE activity \[DOE O
    450.1 § 5.d.(14)\].

-   The ISMS/EMS ensures the implementation of the analytical work
    supporting environmental monitoring, using a consistent system for
    collecting, assessing, and documenting environmental data of known
    and documented quality \[DOE O 450.1 § 5.d. (15)(a)\].

-   The ISMS/EMS ensures the implementation of the analytical work
    supporting environmental monitoring, using a validated and
    consistent approach for sampling and analyzing radionuclide samples
    to ensure laboratory data meet program-specific needs and
    requirements within the framework of a performance-based approach
    for analytical laboratory work \[DOE O 450.1§5.d.(15)(b)\].

-   The ISMS/EMS ensures the implementation of the analytical work
    supporting environmental monitoring, using an integrated sampling
    approach to avoid duplicative data collection \[DOE O 450.1
    §5.d.(15)(c)\].

## The provisions in this task relate to established requirements of the following ISMS elements. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-elements. .sub1}

-   ISMS Core Function 3, "Develop and Implement Hazard Controls:
    Applicable standards and requirements are identified."

-   ISMS Principle 5, "Identification of \[Environment, Safety and
    Health\] Standards and Requirements. Before work is performed, the
    associated hazards shall be evaluated and an agreed-upon set of
    \[environment, safety and health\] standards and requirements shall
    be established . . . ."

    1.  Identifying Environmental Aspects with Regulatory Consequences

Task 3 includes identification of all activities, products, or services
whose aspects have regulatory implications. Because of the ramifications
that regulatory violations might have for a site, it is important that
all aspects with regulatory implications be managed through the
ISMS/EMS. Site environmental and legal personnel should help determine
those legal requirements that apply to environmental aspects on DOE
sites. The site ISMS/EMS team and other parties that the team believes
can contribute (e.g., the site regulatory experts) should list all
environmental aspects whose activities, products, or services are
subject to regulation, as shown in Table 4. Table 3, below, includes a
recommended approach for capturing the regulatory status of a particular
environmental aspect. The appropriate value should be entered beside the
corresponding impact in Table 4.

> Table 3. Regulatory and Other Requirements Related to Environmental
> Aspects

  -----------------------------------------------------------------------
  **Scale of Regulatory and Other Requirements**

  5 = Regulated----Mandated by Federal, host nation, State, or local
  government agency statutes, laws, or regulations or Executive orders
  and DOE regulations or required by DOE directives ***(Automatically
  Significant)***

  4 = Regulated in the Future----Not currently mandated by a government
  agency, but under proposal

  3 = Site Best Management Practice (i.e., not DOE-wide but mandated by
  site management)

  0= No applicable regulatory requirement
  -----------------------------------------------------------------------

The ISMS/EMS team may use a variety of techniques to identify regulated
aspects. In some cases, a brainstorming exercise similar to that
conducted when identifying aspects may be effective. A search of
existing documents such as environmental permits and compliance
agreements may be helpful in identifying regulated activities. In this
case, it is usually important to include a member of the legal staff to
be confident of the regulatory implications of each possible aspect. In
other cases, the responsible environmental expert for that issue may be
able to review each aspect within his or her area of expertise and
provide the ISMS/EMS team with the necessary regulatory information. Any
of these or other methods is suitable as long as it provides a high
degree of certainty regarding the regulatory implications of
environmental aspects.

In Task 3, all aspects with regulatory and policy implications should be
identified and assigned a value of "5" using the rating system shown in
Table 3. In practical terms, those assigned a value of "5" should be
considered significant environmental aspects. As a result, when an
organization identifies its significant environmental aspects, those
that are regulated or governed by external regulation; Executive Orders
(i.e., E.O. 13148, *Greening the Government Through Leadership in
Environmental Management*); or Departmental directives (e.g., DOE O
450.1 or DOE P 450.4) will be automatically designated as significant
aspects.

Aspects that will be regulated in the future are assigned a value of
"4," and site best management practices assigned a value of "3."
Although these aspects may be considered minor, they should be
documented when assigning a score. If there is no applicable
requirement, a value of "0" should be assigned.

2.  Specific Environmental Interactions

After listing all activities, products, and services (see example
Table 1) and identifying their associated environmental aspects, sites
should consider specific environmental interactions and impacts and
develop measurable objectives and targets (see Section 3.1). Through
this process, sites should consider pollution prevention opportunities.

DOE O 450.1 §4b (1), (2), (3), and (4) require consideration for
inclusion, as applicable.

-   Conformity of DOE proposed actions with State Implementation Plans
    to attain national ambient air quality standards;

-   Implementation of watershed approach for surface-water protection;

-   Implementation of site-wide approach for groundwater protection;

-   Protection of other natural resources, including biota;

-   Protection of site resources from wildland and operational fires;

-   Protection of cultural resources;

-   Promotion of long-term stewardship of a site's natural and cultural
    resources;

-   Reduction or elimination of the generation of waste, the release of
    pollutants to the environment, and the use of Class I
    ozone-depleting substances (ODS) through source reduction, reuse,
    segregation, and recycling and by procuring recycled-content
    materials and environmentally preferable products and services;

-   Ensure the early identification of and appropriate response to,
    potential adverse environmental impacts associated with DOE
    operations, including, as appropriate, preoperational
    characterization and assessment, and effluent and surveillance
    monitoring.

  ------------- ---------------------------------- ------------------------------- ---------
  **Env.        **Activities/Products/Services**   **Potential Impacts**           **Reg.
  Aspect**                                                                         Score**

  Air Emissions Using and Storing Chem. Products   General reduction in air        5
                and Chem. Hazardous Agents         quality, and potential human,   
                                                   ecological, and habitat effects 
                                                   in the locality, spreading over 
                                                   a large footprint affecting all 
                                                   media and biota. Noncompliance  
                                                   with applicable                 
                                                   laws/regulations.               

                Constructing or Modifying                                          
                Facilities, Processes, or                                          
                Equipment                                                          

                Deactivating, Decommissioning,                                     
                Dismantling, or Closing                                            
                Facilities, Equipment, and                                         
                Processes                                                          

                Maintaining, Servicing, or                                         
                Repairing Refrigeration and Air                                    
                Conditioning Equipment                                             

                Constructing Hazardous Waste Units                                 

                Combusting fuel for heat, power,                                   
                or electricity                                                     

                Closing Waste Management Units                                     

  Disturbance   Constructing or Modifying          Ecological damage, damage of    5
  of Cultural   Facilities, Processes, or          cultural and historically       
  and           Equipment                          significant artifacts.          
  Historical                                       Noncompliance with applicable   
  Resource                                         laws/regulations.               

                Conducting Open Burning                                            

                Constructing or Modifying                                          
                Aboveground and Underground                                        
                Storage Tanks                                                      

  Releases to   Deactivating, Decommissioning,     Runoff to local rivers and      5
  Wastewater    Dismantling, or Closing            streams with species, habitat,  
  System and    Facilities, Equipment, and         and fisheries impacts. Leaching 
  Groundwater   Processes                          to groundwater (aquifers) and   
                                                   biota of hazardous wastes.      
                                                   Noncompliance with applicable   
                                                   laws/regulations                

                Conducting Research and                                            
                Development                                                        

                Leaks, Spills, and Releases                                        

                Closing Waste Management Units                                     

  Medical Waste Conducting Research and            Ecological damage,              5
  Generation    Development                        contamination of air, water,    
  Management,                                      and soil with biohazards impact 
  and Disposal                                     to human health and biota, and  
                                                   waste generation. Noncompliance 
                                                   with applicable                 
                                                   laws/regulations.               

  Radioactive   Preparing Buildings or Facilities  Ecological damage,              5
  waste         for Transfer to Surplus, Inactive  contamination of air, water,    
  generation    Facility Status or D & D           and soil with radiological      
                                                   contaminants, impact to human   
                                                   health and biota, and waste     
                                                   generation. Noncompliance with  
                                                   applicable laws/regulations.    

                Releases, leaks, spills or unusual                                 
                operating conditions from USTs                                     

                Closing Waste Management Units                                     

                Conducting Research and                                            
                Development                                                        

                Disposition of Excess Materials                                    

                Clean up of Legacy Waste Sites                                     

                Treating, Storing and Disposing of                                 
                Waste                                                              
  ------------- ---------------------------------- ------------------------------- ---------

**2.1.3 Pollution Prevention**

Pollution prevention is not a stand-alone program; rather it is
incorporated into the day-to-day operations at DOE sites. DOE O 450.1 §4
a. (1) requires that all DOE elements ensure that site ISMSs include an
EMS that provides for the systematic planning, integrated execution, and
evaluation of programs for pollution prevention. DOE O 450.1 §4.b.(3)
requires that as part of integrating EMSs into site ISMSs, DOE elements
must reduce or eliminate the generation of waste, the release of
pollutants to the environment, and the use of Class I ODSs through
source reduction, reuse, segregation, and recycling and by procuring
recycled-content materials and environmentally preferable products and
services.

DOE O 450.1 §5.d.(6) requires sites to conduct pollution prevention
opportunity assessments (PPOA) and implement cost effective pollution
prevention solutions. A PPOA is an appraisal of a process, activity, or
operation to identify and evaluate potential pollution prevention
opportunities (see Appendix D, Glossary). Pollution prevention
opportunities should be considered before setting your site's objective
and targets. For example, specific pollution prevention goals were set
forth in a Secretary of Energy Memorandum issued in 1999.[^1]
Site-specific goals that contribute to these existing pollution
prevention goals can be a site's environmental objective for reducing or
eliminating a certain impact (i.e., waste generation or discharge). A
target could be a schedule for conducting a PPOA to identify pollution
prevention solutions for achieving the objective.

Subsequent guidance regarding incorporating pollution prevention
elements into the site's ISMS/EMS will provide additional details.

4.  Clean Air Act General Conformity

Under Section 176(c)(1) of the Clean Air Act (and the Environmental
Protection Agency's implementing regulations at 40 CFR Part 93, or State
or local agency implementing regulations), a Federal agency is
prohibited from carrying out or providing financial assistance for any
activity that does not conform to State efforts to attain or maintain
compliance with the national ambient air quality standards (NAAQS) for
the criteria pollutants (i.e., ozone, nitrogen dioxide, sulfur oxides,
particulate matter, carbon monoxide, and lead). If there are air
emissions of criteria pollutants of concern for a proposed DOE action in
a nonattainment or maintenance area,[^2] the general conformity
regulations require that an analysis of these emissions of pollutants of
concern be carried out prior to the initiation of the proposed action,
preferably in conjunction with the NEPA compliance process. This
analysis is not required for proposed DOE actions that would cause air
emissions to occur in attainment areas (i.e., areas complying with all
NAAQS).

After the site has identified activities, products and services related
to general conformity requirements and how they interact with the
ambient air environment, the ISMS/EMS team may determine the impacts
(and their significance) caused by emission of criteria air pollutants
for the planned DOE action in nonattainment and maintenance areas.

Sites may evaluate environmental impacts by comprehensively estimating
criteria pollutant emissions from proposed DOE actions. If estimated
emissions are greater than either of two conformity *de minimis*
emission levels, the emissions associated with the proposed DOE action
are considered to be of significance, and a more detailed "conformity
determination" is needed.

Examples of potential impacts include---

-   deterioration of air quality,

-   possible greater health hazards to the public due to the DOE action,
    and

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-   noncompliance with conformity regulations.

An example of an environmental objective for conformity is to go beyond
compliance with all conformity regulatory requirements. Examples of
targets are to ensure that all organizations on the site are responsible
for proposed DOE actions in nonattainment and maintenance areas conduct
PPOAs to identify pollution prevention solutions such as reductions in
the use of chemicals that produce criteria pollutants.

Appendix A contains a list of additional guidance materials.

1.  Watershed Approach for Surface-Water Protection

A watershed is defined as a geographic area of land, water, and biota
within the confines of a drainage divide and the total area above a
given point of a water body that contributes flow to that point. Aspects
that impact surface water include, but are not limited to, waste
generation and discharge to the watershed, spills from raw material
storage, construction and maintenance, fresh water and energy
consumption, solid waste generation and disposal, and radiation.

Examples of potential impacts include---

-   reduction of fresh water supply,

-   reduction in the number of flora and fauna, and

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-   degradation of water quality.

An example of an environmental objective for watershed management might
be the use of a consistent, science-based, approach to watershed
assessments. A target might be to ensure compliance with applicable
regulatory requirements.

Appendix A contains a list of additional guidance materials.

1.  Site-Wide Approach for Groundwater Protection

After the site has identified activities, products and services that
could impact groundwater quality, the site may determine the impacts
(and their significance) caused by such actions. Since groundwater can
be affected by any operating facility or activity, the ISMS/EMS should
provide a framework whereby all efforts to protect groundwater are
integrated, including, but not limited to, the following:

-   integration of active remediation of contaminated groundwater with
    prevention of future groundwater contamination,

-   integration of compliance with external and internal regulatory
    requirements,

-   integration of ongoing program activities and facilities with
    site-wide landlord responsibilities, and

-   integration of all groundwater and vadose zone monitoring
    activities.

Using the systems approach to groundwater protection allows for
flexibility in the long term and should address current needs, be able
to adapt to changes over time, and serve as a repository for historic
groundwater activities, documents, and data. The site-wide approach can
also address the needs for long-term protection, including surveillance
and maintenance (see Section 2.1.10). Current needs are determined by
specific requirements included in applicable permits and compliance
agreements. Long-term needs are determined by the sources of potential
future releases that will remain at the site after DOE operations cease
and the completion of active remediation.

The site-wide groundwater protection approach should be tailored to each
DOE site's unique physical setting, history, current mission, and local
or regional cultural characteristics. There are, however, certain
objectives that are common to all DOE sites, and that should be
reflected in each site ISMS/EMS.

Examples of objectives for groundwater protection include the following.

-   Develop a strategy for controlling existing contamination and
    pursuing site-wide pollution prevention goals for preventing future
    contamination.

-   Establish and maintain a process for identifying possible future
    sources of contamination.

-   Ensure that all external and internal regulatory requirements are
    met.

-   Maintain documentation of all measures used for monitoring the
    groundwater and vadose zone.

-   Maintain a consolidated system for documenting the quality of
    ambient groundwater and vadose zone conditions and reporting the
    results of groundwater and vadose zone monitoring.

-   Maintain a process of program review and evaluation that includes
    regular evaluation of technical improvements and cost-effective
    technologies.

Targets may be set to---

-   ensure compliance with applicable regulatory requirements,

-   identify and document possible future sources of contamination,

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-   prevent contamination, and

-   ensure dates for completing PPOAs are set.

Appendix A contains a list of additional guidance materials.

1.  Natural Resources---Biota

Biota is defined as the plant and animal life in a particular region.
After the site has identified activities, products, and services related
to interactions with biota, the site may then determine the impacts (and
their significance) caused by such actions.

When determining the environmental impacts to biota, sites should use
evaluation methods that consider---

-   site-related physical, chemical, and radiological hazards;

-   routes of exposure to biota from these hazards or sources;

-   potential for harm or reduction in biota populations;

-   actual or potential habitat loss that could directly or indirectly
    impact biota populations;

-   noncompliance with permits, limits and standards; and

-   associated costs and schedule impacts to site operations,
    decontamination and decommissioning, and property and land transfer
    as a result of impacts to biota or noncompliance with biota
    protection requirements.

Guidance for evaluating potential radiological impacts to biota is
provided in the DOE Technical Standard, *A Graded Approach for
Evaluating Radiological Doses to Aquatic and Terrestrial Biota*
(DOE-STD-1153-2002). Sites should consider other requirements,
standards, and guidance for protection of biota as appropriate (see
Appendix A).

Examples of objectives for biota may include the following.

-   Demonstrate to DOE, local regulators, and stakeholders that
    radioactive discharges and residual radioactive contamination on
    site lands does not impact biota.

-   Determine that there are no significant impacts to biota associated
    with site activities and their associated environmental aspects.

Examples of targets for biota may include the following.

-   Conduct biota dose evaluations for 80 percent of site operable
    units, facilities, or other defined evaluation areas within a
    specific timeframe and document the results of these biota dose
    evaluations in the site's ASER.

-   Determine if additional monitoring is needed or if the existing
    sampling program (e.g., locations and frequencies) needs refinement
    or augmentation.

-   Promote awareness of biota protection activities to local regulators
    and stakeholders.

-   Provide evidence that potential impacts to biota have been evaluated
    through a systems approach considering all relevant site activities
    and associated environmental aspects, and that any significant
    impacts to biota are identified and being addressed in the site EMS.

-   Develop procedures for evaluating radiation doses to biota and
    needed monitoring are in place.

-   Develop procedures for addressing noncompliance with permits,
    standards, and limits for biota protection are in place.

-   Provide evidence that biota evaluation and protection activities are
    going beyond reactive compliance, and are fostering continuous
    improvement.

Appendix A contains a list of additional guidance materials.

1.  Wildland Fire Management Program

Existing wildland fire management programs should be adopted into the
site's ISMS/EMS where appropriate. Most sites' wildland fire management
programs are already institutionalized (for example, emergency
preparedness and response, roles and responsibilities, and training).
This should facilitate inclusion of environmental aspects related to
wildland fires in a site's ISMS/EMS. Guidance regarding incorporation of
wildland fire considerations in the site's management system is
available in draft DOE G 450.1-9.

Appendix A contains a list of additional guidance materials.

2.  Cultural Resources Management Program

Existing cultural resources management programs should be adopted into a
site's ISMS/EMS where appropriate. Guidance regarding incorporating
cultural resources elements into the site's ISMS/EMS, are available in
draft DOE G 450.1-3, *Environmental Guidelines for Development of
Cultural Resource Management Plans-Update*. This guidance document
provides guidelines to organizations responsible for the development of
a Cultural Resources Management Plan (CRMP). As with all guidance, each
site should consider individual needs and tailor the elements of the
CRMP for incorporation into the site's ISMS/EMS.

Appendix A contains a list of additional guidance materials.

3.  Long-Term Stewardship Program

DOE O 450.1 §4.b. (2) requires that, as part of integrating EMSs into
site ISMSs, DOE elements must promote the long-term stewardship (LTS) of
a site's natural and cultural resources throughout its operational,
closure, and postclosure life cycle. LTS is a Department-wide
responsibility and a component of all aspects of Departmental decision
making. One effective and efficient way to implement the sound
stewardship practices sought by DOE is by weaving pollution prevention
technologies, practices, and policies into the EMS continuous cycle of
planning, implementing, evaluating, and improving the organizations
environmental performance. The following should be considered when
setting objectives and targets:

-   approaches to avoid, delay, or reduce the frequency or impact of
    harmful exposures to hazardous substances remaining after DOE
    cleanup projects and other operations are completed;

-   approaches to ensure sustainable design, construction, and operation
    of new facilities and avoid creating waste and contamination
    problems that will require long-term stewardship; and

-   approaches to ensure the use of improved technologies and
    institutional structures to improve reliability and reduce the costs
    of long-term stewardship.

Setting objectives and targets for LTS may require the ISMS/EMS team to
interact with stakeholders and State, local, and tribal governments.
Each site should consider its individual needs and tailor the elements
of the LTS program into the site ISMS/EMS. (A subsequent Guide devoted
to implementation of LTS into the ISMS/EMS will provide additional
details.)

1.  Preoperational Characterization and Assessment; Effluent and
    Surveillance Monitoring

DOE O 450.1 § 4.b(4) requires that as part of integrating EMSs into site
ISMSs, DOE elements must ensure the early identification of, and
appropriate response to, potential adverse environmental impacts
associated with DOE operations, including, as appropriate,
preoperational characterization and assessment, and effluent and
surveillance monitoring. The ISMS/EMS should include adequate monitoring
of environmental media to detect releases from facilities and
operations, and to evaluate the impact of these releases on the general
public and environmental resources.

Specific monitoring elements include the following:

-   monitoring effluents from discharge points and air emissions from
    existing sources to ensure regulatory compliance and to assess
    potential impacts on the public and on the environment,

-   preoperational monitoring to provide an adequate baseline of
    environmental conditions for new facilities or operations,

-   meteorological monitoring to provide accurate environmental
    transport parameters for assessing potential exposure and dose, and

-   using environmental surveillance (air, ground, surface water, vadose
    zone) to detect potential releases at the earliest possible time to
    ensure appropriate response.

Sites should conduct all environmental monitoring in an integrated
fashion to ensure that the environmental stewardship responsibilities
are met in a cost-effective manner. To achieve a fully integrated
environmental monitoring program, the design of monitoring networks
should meet site-wide needs for environmental measurements and facility-
and area‑specific surveillance monitoring needs. The environmental
monitoring networks should be---

-   designed to provide specific data on environmental conditions to
    ensure that facilities and operations are managed to have minimal
    impact on the environment;

-   reevaluated by periodic assessment of the potential impact on the
    environment of each facility and operating program at the site;

-   optimized regularly to ensure the provision of adequate data, given
    changing conditions over time, and that data produced by the
    networks are not duplicative or unnecessary; and

-   designed to serve as the basis for long-term environmental
    stewardship monitoring for the period of time following cessation of
    active DOE operations.

Each DOE site will address monitoring differently and may tailor the
monitoring program in response to unique site conditions. The following
elements should be included in each site's environmental monitoring
program:

-   sampling and analysis plan;

-   surveillance or detection monitoring network;

-   contingency plan that includes specific actions to be taken by
    specific individuals or organizations to take in response to certain
    monitoring results;

-   site-wide vulnerability assessment process to identify priority
    areas for surveillance monitoring;

-   site-wide subsurface characterization process for groundwater and
    vadose zone monitoring;

-   prioritization system, based on vulnerability assessments, to
    determine the focus of surveillance monitoring and for estimating
    the site-wide surveillance monitoring program budget;

-   integrated site-wide monitoring data management and reporting
    system;

-   monitoring system maintenance plan;

-   well abandonment monitoring and closure procedures for groundwater
    monitoring;

-   detailed Quality Assurance/Quality Control (QA/QC) procedures
    designed for the specific data needs of the users of the results of
    each monitoring network; and

-   external peer review process for assisting in periodic program
    performance assessments.

To ensure that the adequacy and utility of the site-wide environmental
monitoring networks are maintained over time, each site's monitoring
program should include a process for periodic review and evaluation. The
following criteria should be used in any periodic review of
environmental monitoring program performance.

-   The network provides sufficient quantitative data of appropriate
    quality for environmental resources management.

-   The network provides sufficient quantitative data of appropriate
    quality for regulatory compliance, to include assessments of
    potential doses to the public.

-   The program includes descriptions of each facility-specific and
    area-specific network, linking anticipated monitoring results with
    the stated purpose of the network's design and the needs of the
    users of the data.

-   The program maintains documentation of current size, scope, and
    technical specifications of each network, as well as historical data
    on the network's design and operations.

-   The program includes processes that ensure periodic evaluation of
    the network's efficiency and cost-effectiveness for continuous
    improvement.

-   The program ensures that data provided by the network meet the
    site's needs.

-   The program provides processes for periodic review of alternative
    and innovative monitoring methods.

-   The program includes regular analyses of long-term trends in
    environmental data quality.

-   The program includes processes to ensure that environmental data
    quality is comparable across environmental media, and the consistent
    gathering and reporting of data over time.

    1.  Environmental Quality Systems

DOE O 450.1 §5(d)(15) requires DOE elements to ensure that the
analytical work supporting environmental monitoring is implemented
using---

-   a consistent system for collecting, assessing, and documenting
    environmental data of known and documented quality;

-   a validated and consistent approach for sampling and analysis of
    radionuclide samples to ensure laboratory data meet program-specific
    needs and requirements within the framework of a performance-based
    approach for analytical laboratory work; and

-   an integrated sampling approach to avoid duplicative data
    collection.

The Uniform Federal Policy for Implementing Environmental Quality
Systems (UFP-QS) offers an implementation tool for meeting this
requirement. The UFP-QS is based on the American National Standards
Institute/American Society for Quality Control E-4 (ANSI/ASQC E4, 1994).
The Quality System (QS) is a structured and documented management system
(to be integrated into the site ISMS/EMS) that provides recommendations
to Federal agencies for documenting and implementing a quality system
for the management of environmental data collection and use. It ensures
that data used to support environmental decisions are of adequate
quality and usability for the intended purpose. The overall goal of this
consensus system is simple: sound decisions must be based on sound
documented data.

The QS is documented, at the organizational level, in a Quality
Management Plan (QMP). The QMP details information by which the
organization will manage, plan, implement, assess, and continually
improve the activities involved in environmental data collection and
use[^3]. At the project level the QS is documented in a Uniform Federal
Policy for Quality Assurance Project Plan (UFP-QAPP).[^4]

The objectives of the UFP-QS are to---

-   provide essential elements of a quality system for management of
    environmental data collection and use;

-   provide a framework to Federal agencies for documenting and
    implementing an acceptable intergovernmental quality system based on
    an approved standard, (ANSI/ASQC E-4 1994, Part A); and,

-   provide guidance to document, assess, and improve existing quality
    systems.

The following are examples of targets.

-   Consolidating site-wide data collection across projects, programs,
    and media; enhancing knowledge communication; and using a graded
    approach to optimize and conserve valuable resources.

-   Establishing a process to maintain a link among systematic planning,
    implementation, and assessment stages of environmental data
    collection to ensure that the data produced meet their intended
    purposes and are documented and defensible.

-   Establishing a validated and consistent approach for sampling and
    analysis of radionuclide samples to ensure laboratory data meet
    program-specific needs and requirements within the framework of a
    performance-based approach for analytical laboratory work.

Appendix A contains additional guidance materials.

## TASK 4: Determine Significance Based on Environmental and Organizational Consideration  {#task-4-determine-significance-based-on-environmental-and-organizational-consideration .H2}

## Reference {#reference-1 .sub1}

## This task fulfills the DOE Order requirement listed below. {#this-task-fulfills-the-doe-order-requirement-listed-below. .sub1}

-   All DOE elements must ensure that the site ISMS include an EMS that
    does the following: Includes policies, procedures, and training to
    identify activities with significant environmental impacts; to
    manage, control, and mitigate the impacts of these activities; and
    to assess performance and implement corrective actions where needed
    \[DOE O 450.1 § 4.a.(2)\].

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element.-2 .sub1}

-   ISMS Core Function 2, "Analyze the Hazards: Hazards associated with
    the work are identified, analyzed and categorized."

There is no scientific test for determining "significance"; as such, the
term is used in a subjective and flexible manner. It is ultimately up to
the site to determine what constitutes significance. However, this task
attempts to provide criteria for that determination that are both
applicable and relevant to DOE site operations.

Numerous factors influence whether an *environmental aspect* is a
*significant environmental aspect*. To identify the organization's
significant environmental aspects, the site must consider these factors
systematically and appropriately as described in the following sections
to protect the environment and support the organization's environmental
policy and mission priorities.

1.  "Significance" in the NEPA and ISMS/EMS Context

There are similarities and differences in the basis for determining
significance in the context of the ISMS/EMS and NEPA. The criteria for
"likelihood" and "environmental consequence" used to identify
significant environmental aspects in an ISMS/EMS are consistent with the
criteria for assessing potential significance in NEPA, even though their
application may be different in the two processes. The criteria for
"mission consequence" may not factor into a determination of significant
impacts under NEPA, however, there are instances where the Department's
NEPA documents do consider potential mission impact.

When identifying significant environmental aspects in ISMS/EMS planning,
staff members should be aware whether those aspects have been addressed
through the NEPA process and whether they are identifying information
that might trigger the need for a NEPA review or that should be part of
an otherwise planned NEPA review. Conversely, the NEPA process may
identify aspects that are significant for the site's ISMS/EMS, or may
resolve such significant aspects (e.g., through mitigation commitments).

Another situation in which the relationship is important is when
evaluating new proposals. In the NEPA context, the significance of
potential environmental impacts is most relevant when evaluating a
proposed major Federal action. The ISMS/EMS should account for this by
encouraging an awareness of NEPA requirements and existing NEPA
documentation during the assessment of environmental aspects for new
proposals. In many circumstances, some environmental aspects would be
significant for both NEPA and EMS, while in others they might be
significant for one but not the other.

2.  Criteria for Scoring Likelihood of Occurrence

One of the factors in scoring the significance of an aspect is the
likelihood that its impact will occur. In this Guide, we use likelihood
to score both the environmental consequence and the mission consequence
of environmental impacts. Both the environmental and mission
consequences are multiplied by the likelihood that the impact will occur
for a given aspect. For example, surface-water contamination is an
impact of the aspect hazardous materials spills (i.e., spills are an
interaction with the environment). To determine the significance of
these spills, it is important to understand the probability that spills
will occur and the probability that contamination (i.e., impact) will
occur. If contamination will never occur because no work occurs
outdoors, then hazardous materials spills will not be significant for
surface-water contamination. However, if indoor spills occur often and
are flushed into the storm sewer system, then that hazardous materials
spill may be designated significant on the basis of the likelihood of
surface-water contamination.

Providing an estimate of the likelihood of an impact occurring helps to
select the aspects that are the most significant to the environment and
to the organization's mission. Table 5 provides a rating system for
assigning the relative likelihood that an impact will occur for a given
aspect (e.g., the chance of contamination occurring while managing
waste). The assigned value should be entered into the Likelihood column
of Table 8 in Section 2.2.5.

Table 5. Sample criteria for scoring the likelihood of occurrence

+--------------------------------------------------+-------------------+
| **Estimated chance that the impact will occur    | **Likelihood      |
| (e.g., contamination of surface water) for a     | Score**           |
| given aspect (e.g., a hazardous material spill)  |                   |
| for a given time period**                        |                   |
+--------------------------------------------------+-------------------+
| > Very Frequently                                | 5                 |
+--------------------------------------------------+-------------------+
| > Frequently                                     | 4                 |
+--------------------------------------------------+-------------------+
| > Occasionally                                   | 3                 |
+--------------------------------------------------+-------------------+
| > Infrequently                                   | 2                 |
+--------------------------------------------------+-------------------+
| > Rarely                                         | 1                 |
+--------------------------------------------------+-------------------+

Likelihood indicates the chance that an impact will occur. Therefore, it
is important to obtain information from facility personnel with
experience in site activities, who provides an indication of the chance
that the aspect will occur (e.g., a spill when filling tanks) and from
individuals who can provide a rough estimate of the chance that the
impact will occur (e.g., surface-water contamination) if the spill
happens. These estimates are likely to be based on subjective
experience. When available, the ISMS/EMS team should give preference in
its estimates to records that show objective data of actual occurrences.

3.  Criteria for Scoring Environmental Consequences of Impacts

Another important component of an aspect's significance is the
consequence of the potential impact. For example, if two hazardous
materials spills, (A) and (B), occur during an organization's operations
with equal frequency, they may be equally significant on the basis of
likelihood. However, if (A) is volatile and evaporates almost
immediately (i.e., becoming inert) and (B) is soluble and highly
persistent (i.e., will stay in the environment for many years), the two
spills have difference consequences for the environment. In this case,
the site may designate spill (B) as significant based on the consequence
of its impact to the environment (i.e., it is soluble and highly
persistent and therefore greater risk of contamination).

After the likelihood of an impact has been determined, the next step is
to determine the relative environmental consequence of the impact. Table
6 provides an approach for scoring the consequence of the environmental
impacts of each aspect. The second column of Table 6 provides a few
common characteristics that the site should consider when making this
determination. The two main factors are the proximity of that aspect to
sensitive receptors and the severity of harm that the aspect's impact
can cause to the environment. The importance the site places on these
various characteristics depends on site conditions and priorities. The
resulting score that is generated for a particular aspect should be
transferred to the environmental score column in Table 8.

4.  Criteria for Scoring Mission Consequences

The second type of consequence that needs to be evaluated to determine
overall significance is the consequence of a potential environmental
impact for the continued accomplishment of the site's mission. This
consideration will help ensure that a site's ISMS/EMS is mission focused
and that it sets priorities not just on the basis of potential
environmental impact, but also on the basis of impact on core DOE
missions. DOE's overarching mission is to advance the national economic
and energy security of the United States to promote scientific and
technological innovation in support of that mission; and to ensure the
environmental cleanup of the national nuclear weapons complex. Further,
one of the four strategic goals is to protect the environment by
providing a responsible resolution to the environmental legacy of the
Cold War and by providing for the permanent disposal of the Nation's
high-level radioactive waste.

Table 7 provides an approach that can be used to determine the level of
mission impact that an adverse environmental impact could have. For
example, if a cleanup activity for the removal of contaminated soils
required by the Comprehensive Environmental Response, Compensation and
Liability Act (CERCLA) uncovers cultural/historical artifacts, and work
cannot proceed until after the removal of the artifacts in an
appropriate manner, then the mission of removing contaminated soil is
delayed past a scheduled milestone the activity should be considered a
significant mission consequence (score of 5).

Table 6. Sample criteria for scoring environmental consequences on DOE
sites

+--------------+-------------------------------------------------------+
| **E          | **Environmental Consequence Considerations**          |
| nvironmental |                                                       |
| Consequence  | *These general characteristics should be taken into   |
| Scale**      | account when determining the environmental            |
|              | consequences of an aspect.*                           |
+--------------+-------------------------------------------------------+
| 5 = Severe/  | *Toxicity/Hazard*: The relative toxicity of the       |
| Catast       | consequence (including attributes such as exposure    |
| rophic--Very | pathway in the environment, mobility of a compound in |
| harmful or   | the environment, persistence or bioaccumulation).     |
| potentially  |                                                       |
| fatal; great | *Quantity*: Generally the size of the consequence     |
| effort to    | (quantity of site scrap generated, gallons of water   |
| correct and  | consumed) produced/used per year.                     |
| recover      |                                                       |
|              | *Duration*: The length of time that the consequence   |
| 4 =          | will be felt by affected entities (noise impacts are  |
| Seri         | generally short term, whereas contamination of an     |
| ous--Harmful | aquifer with lead or radioactive material generally   |
| but not      | creates a long-term impact).                          |
| potentially  |                                                       |
| fatal,       | *Geographic Boundaries*: Reflects the size of the     |
| difficult to | physical area in which the consequence occurs (a      |
| correct but  | 10-gallon diesel fuel spill may affect a few cubic    |
| recoverable  | feet of soil, whereas contamination of a local river  |
|              | with sediment or pollutants may impact the ecosystem  |
| 3 =          | of an entire watershed).                              |
| Modera       |                                                       |
| te--Somewhat | *Proximity of Consequence to People or Sensitive      |
| harmful;     | Environmental Receptors*: The closeness of an impact  |
| correctable  | to sensitive environmental receptors such as those    |
|              | listed below.                                         |
| 2 =          |                                                       |
| Mild--Little | > *Cultural resources* \[threatens (mild or           |
| potential    | > moderate), disturbs/damages (serious), or destroys  |
| for harm;    | > (severe) historic properties, cultural landscapes,  |
| correctable  | > cultural items, archaeological resources, Indian    |
|              | > sacred sites, cemeteries\].                         |
| 1 =          | >                                                     |
| Insignific   | > *Biota* \[threatens (\[mild or moderate), alters    |
| ant--Trivial | > (moderate or serious), or destroys (severe)         |
| harm/        | > sensitive natural and ecological resources such as  |
| consequence; | > wetlands, threatened and endangered species,        |
| easily       | > critical habitats, sole‑source aquifers, etc.\].    |
| correctable  | >                                                     |
|              | > *People* \[poses acute or chronic (serious or       |
|              | > moderate) or temporary (mild or moderate) risks to  |
|              | > human health because of the impact's proximity to   |
|              | > schools, public stakeholders, employees, hospitals, |
|              | > housing, recreational areas, drinking water\].      |
+--------------+-------------------------------------------------------+

Table 7. Sample criteria for scoring mission consequences for DOE sites

  -----------------------------------------------------------------------
  **Mission Impact Scale**

  5 = Loss of ability to accomplish mission ***([Automatically
  Significant)]{.underline}***

  4 = Mission restrictions/impacts

  3 = Moderate mission restrictions/impacts

  2 = Minor mission restrictions/impacts

  1 = Insignificant mission restrictions/impacts

  0 = No mission restrictions/impacts
  -----------------------------------------------------------------------

As discussed above, the likelihood that an impact will occur is also
used when scoring the mission impact. The criteria in Table 7 are
applied to a given potential environmental impact that is present in an
activity, product or service. To apply the criteria in Table 7, ask the
following question: If this potential environmental impact were to
actually occur in this activity, what would be the probable mission
consequences (from among those listed in Table 7)?

5.  Determination of Overall Impact Score

Once each aspect has been evaluated for regulatory status, likelihood of
impact, environmental consequence, and mission consequence, the ISMS/EMS
team can then score it for overall significance through use of the
following equation.

Significance Score = (Likelihood x Env. Consequence) + (Likelihood x
Mission Consequence) + Regulatory Status .

The ISMS/EMS team then decides on the overall impact score threshold
above which an aspect is to be considered a *significant environmental
aspect*. For example, the selected numerical threshold indicating
significance in Table 8 was a score above 30 (therefore, impacts scoring
30 and below are not significant on the basis of their overall impact
scores). The team determines the establishment of this cutoff value
based on site considerations that should include account resources,
risks, mission impact and priorities.

This overall score also serves as a useful factor for allocating
resources in the EMPs. In general, the higher the score, the more
opportunity and incentive for improvement. In other words, a higher
overall score generally represents a higher payback potential in terms
of lowering risks.

The three tests below are the recommended criteria for determining
significance on DOE sites. The highlighted fields in Table 8 indicate
significance.

-   Overall impact score above some site-selected threshold value
    (Overall Score column, Table 8)

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-   Mission impact score of "5" (Mission Score column, Table 8)

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-   Regulatory status score of "5" (Reg. Score column, Table 8)

Table 8a illustrates how the site could rank environmental aspects for
overall significance based on environmental and organizational
considerations. As discussed previously, our examples use a score
greater than 30 as the threshold for determining significance. With an
overall score of 45, radioactive waste generation has the highest score.
When allocating resources in the EMP, this environmental aspect would
receive the highest priority.

Table 8. Determination of significance based on environmental and
organizational considerations

+------+-------------------+---------------------+---+---+---+---+---+--------+
| **   | **Activities/     | **Potential         | * | * | * | * | * | **     |
| Env. | Pr                | Impacts**           | * | * | * | * | * | Signif |
| Aspe | oducts/Services** |                     | R | E | M | L | O | icance |
| ct** |                   |                     | e | n | i | i | v | based  |
|      |                   |                     | g | v | s | k | e | on**   |
|      |                   |                     | . | i | s | e | r |        |
|      |                   |                     | S | r | i | l | a | **1.   |
|      |                   |                     | c | o | o | i | l | o      |
|      |                   |                     | o | n | n | h | l | verall |
|      |                   |                     | r | m | S | o | S | score  |
|      |                   |                     | e | e | c | o | c | \>30** |
|      |                   |                     | * | n | o | d | o |        |
|      |                   |                     | * | t | r | S | r | **2.   |
|      |                   |                     |   | a | e | c | e | reg.   |
|      |                   |                     |   | l | * | o | * | S      |
|      |                   |                     |   | S | * | r | * | core** |
|      |                   |                     |   | c |   | e |   |        |
|      |                   |                     |   | o |   | * |   | **3.   |
|      |                   |                     |   | r |   | * |   | m      |
|      |                   |                     |   | e |   |   |   | ission |
|      |                   |                     |   | * |   |   |   | s      |
|      |                   |                     |   | * |   |   |   | core** |
+------+-------------------+---------------------+---+---+---+---+---+--------+
| Air  | Using and Storing | General reduction   | 5 | 4 | 3 | 3 | 2 | Signi  |
| E    | Chem. Products    | in air quality, and |   |   |   |   | 6 | ficant |
| miss | and Chem.         | potential human,    |   |   |   |   |   | on:    |
| ions | Hazardous Agents  | ecological, and     |   |   |   |   |   |        |
|      |                   | habitat effects in  |   |   |   |   |   | Reg.   |
|      |                   | the locality,       |   |   |   |   |   | Score  |
|      |                   | spreading over a    |   |   |   |   |   |        |
|      |                   | large footprint     |   |   |   |   |   |        |
|      |                   | affecting all media |   |   |   |   |   |        |
|      |                   | and biota.          |   |   |   |   |   |        |
|      |                   | Noncompliance with  |   |   |   |   |   |        |
|      |                   | applicable          |   |   |   |   |   |        |
|      |                   | laws/regulations.   |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Constructing or   |                     |   |   |   |   |   |        |
|      | Modifying         |                     |   |   |   |   |   |        |
|      | Facilities,       |                     |   |   |   |   |   |        |
|      | Processes, or     |                     |   |   |   |   |   |        |
|      | Equipment         |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Deactivating,     |                     |   |   |   |   |   |        |
|      | Decommissioning,  |                     |   |   |   |   |   |        |
|      | Dismantling, or   |                     |   |   |   |   |   |        |
|      | Closing           |                     |   |   |   |   |   |        |
|      | Facilities,       |                     |   |   |   |   |   |        |
|      | Equipment, and    |                     |   |   |   |   |   |        |
|      | Processes         |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Maintaining,      |                     |   |   |   |   |   |        |
|      | Servicing or      |                     |   |   |   |   |   |        |
|      | Repairing         |                     |   |   |   |   |   |        |
|      | Refrigeration and |                     |   |   |   |   |   |        |
|      | Air Conditioning  |                     |   |   |   |   |   |        |
|      | Equipment         |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Constructing      |                     |   |   |   |   |   |        |
|      | Hazardous Waste   |                     |   |   |   |   |   |        |
|      | Units             |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Combusting fuel   |                     |   |   |   |   |   |        |
|      | for heat, power   |                     |   |   |   |   |   |        |
|      | or electricity    |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Closing Waste     |                     |   |   |   |   |   |        |
|      | Management Units  |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
| Dis  | Constructing or   | Ecological damage,  | 5 | 3 | 3 | 2 | 1 | Signi  |
| turb | Modifying         | damage of           |   |   |   |   | 7 | ficant |
| ance | Facilities,       | culturally and      |   |   |   |   |   | on:    |
| of   | Processes, or     | historically        |   |   |   |   |   |        |
| Cult | Equipment         | significant         |   |   |   |   |   | Reg.   |
| ural |                   | artifacts.          |   |   |   |   |   | Score  |
| Hi   |                   | Noncompliance with  |   |   |   |   |   |        |
| stor |                   | applicable          |   |   |   |   |   |        |
| ical |                   | laws/regulations.   |   |   |   |   |   |        |
| R    |                   |                     |   |   |   |   |   |        |
| esou |                   |                     |   |   |   |   |   |        |
| rces |                   |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Conducting Open   |                     |   |   |   |   |   |        |
|      | Burning           |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Constructing or   |                     |   |   |   |   |   |        |
|      | Modifying         |                     |   |   |   |   |   |        |
|      | Aboveground and   |                     |   |   |   |   |   |        |
|      | Underground       |                     |   |   |   |   |   |        |
|      | Storage Tanks     |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
| Rele | Deactivating,     | Runoff to local     | 5 | 4 | 3 | 4 | 3 | Signi  |
| ases | Decommissioning,  | rivers and streams  |   |   |   |   | 3 | ficant |
| to   | Dismantling, or   | with species,       |   |   |   |   |   | on:    |
| Wa   | Closing           | habitat, and        |   |   |   |   |   |        |
| stew | Facilities,       | fisheries impacts.  |   |   |   |   |   | Reg.   |
| ater | Equipment, and    | Leaching to         |   |   |   |   |   | Score  |
| Sy   | Processes         | groundwater         |   |   |   |   |   |        |
| stem |                   | (aquifers) and      |   |   |   |   |   | O      |
| and  |                   | biota.              |   |   |   |   |   | verall |
| Gro  |                   | Noncompliance with  |   |   |   |   |   | Score  |
| undw |                   | applicable          |   |   |   |   |   |        |
| ater |                   | laws/regulations.   |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Conducting        |                     |   |   |   |   |   |        |
|      | Research and      |                     |   |   |   |   |   |        |
|      | Development       |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Leaks, Spills,    |                     |   |   |   |   |   |        |
|      | and Releases      |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Closing Waste     |                     |   |   |   |   |   |        |
|      | Management Units  |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
| Med  | Conducting        | Ecological damage,  | 5 | 4 | 4 | 1 | 1 | Signi  |
| ical | Research and      | contamination of    |   |   |   |   | 3 | ficant |
| W    | Development       | air, water and soil |   |   |   |   |   | on:    |
| aste |                   | with biohazards,    |   |   |   |   |   |        |
| Gen  |                   | impacts to human    |   |   |   |   |   | Reg.   |
| erat |                   | health and biota,   |   |   |   |   |   | Score  |
| ion, |                   | waste generation    |   |   |   |   |   |        |
| Ma   |                   | Noncompliance with  |   |   |   |   |   |        |
| nage |                   | applicable          |   |   |   |   |   |        |
| ment |                   | laws/regulations.   |   |   |   |   |   |        |
| and  |                   |                     |   |   |   |   |   |        |
| Disp |                   |                     |   |   |   |   |   |        |
| osal |                   |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
| Rad  | Preparing         | Ecological damage,  | 5 | 5 | 5 | 4 | 4 | Signi  |
| ioac | Buildings or      | contamination of    |   |   |   |   | 5 | ficant |
| tive | Facilities for    | air, water and soil |   |   |   |   |   | on:    |
| w    | Transfer to       | with radiological   |   |   |   |   |   |        |
| aste | Surplus, Inactive | material, impacts   |   |   |   |   |   | Reg.   |
| ge   | Facility Status   | to human health and |   |   |   |   |   | Score  |
| nera | or D & D          | biota, waste        |   |   |   |   |   |        |
| tion |                   | generation.         |   |   |   |   |   | M      |
|      |                   | Noncompliance with  |   |   |   |   |   | ission |
|      |                   | applicable          |   |   |   |   |   | Score  |
|      |                   | laws/regulations.   |   |   |   |   |   |        |
|      |                   |                     |   |   |   |   |   | O      |
|      |                   |                     |   |   |   |   |   | verall |
|      |                   |                     |   |   |   |   |   | Score  |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Releases, leaks,  |                     |   |   |   |   |   |        |
|      | spills or unusual |                     |   |   |   |   |   |        |
|      | operating         |                     |   |   |   |   |   |        |
|      | conditions from   |                     |   |   |   |   |   |        |
|      | USTs              |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Closing Waste     |                     |   |   |   |   |   |        |
|      | Management Units  |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Conducting        |                     |   |   |   |   |   |        |
|      | Research and      |                     |   |   |   |   |   |        |
|      | Development       |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Disposition of    |                     |   |   |   |   |   |        |
|      | Excess Materials  |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Cleanup of Legacy |                     |   |   |   |   |   |        |
|      | Waste Sites       |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+
|      | Treating, Storing |                     |   |   |   |   |   |        |
|      | and Disposing of  |                     |   |   |   |   |   |        |
|      | Waste             |                     |   |   |   |   |   |        |
+------+-------------------+---------------------+---+---+---+---+---+--------+

Table 8a. Rank of overall significance based on environmental and
organizational considerations.

+----------------+------------------+--------------+------------------+
| *              | **Significance   | **Overall    | **Rank as a      |
| *Environmental | based on**       | Score**      | significant      |
| Aspect**       |                  |              | environmental    |
|                | **overall        |              | impact**         |
|                | score**          |              |                  |
+----------------+------------------+--------------+------------------+
| Air Emissions  | Significant on:  | > 26         | 3                |
|                |                  |              |                  |
|                | Regulatory Score |              |                  |
+----------------+------------------+--------------+------------------+
| Disturbance of | Significant on:  | > 17         | 4                |
| Cultu          |                  |              |                  |
| ral/Historical | Regulatory Score |              |                  |
| Resources      |                  |              |                  |
+----------------+------------------+--------------+------------------+
| Releases to    | Significant on:  | > 33         | 2                |
| Wastewater     |                  |              |                  |
| System and     | Regulatory Score |              |                  |
| Groundwater    |                  |              |                  |
|                | Overall Score    |              |                  |
+----------------+------------------+--------------+------------------+
| Medical Waste  | Significant on:  | > 13         | 5                |
| Generation,    |                  |              |                  |
| Management and | Regulatory Score |              |                  |
| Disposal       |                  |              |                  |
+----------------+------------------+--------------+------------------+
| Radioactive    | Significant on:  | > 45         | 1                |
| Waste          |                  |              |                  |
| Generation     | Regulatory Score |              |                  |
|                |                  |              |                  |
|                | Mission Score    |              |                  |
|                |                  |              |                  |
|                | Overall Score    |              |                  |
+----------------+------------------+--------------+------------------+

# Setting Objectives and Targets {#setting-objectives-and-targets .H1}

![](media/image4.wmf){width="6.498611111111111in"
height="1.6277777777777778in"}

## TASK 5: Develop Objectives and Targets To Address Significant Aspects {#task-5-develop-objectives-and-targets-to-address-significant-aspects .H2}

## References {#references-2 .sub1}

## This task fulfills several DOE Order requirements listed below. {#this-task-fulfills-several-doe-order-requirements-listed-below.-1 .sub1}

##  {#section .sub1}

-   The ISMS/EMS includes measurable environmental goals, objectives,
    and targets \[DOE O 450.1 §4.a.(3)\].

-   The ISMS/EMS includes site-specific goals that contribute to the
    accomplishment of DOE pollution prevention and energy efficiency
    goals \[DOE O 450.1 §5.c.(3)\].

-   Contractor ES&H performance objectives, performance measures, and
    commitments include appropriate environmental elements based on the
    environmental risks, impacts of activities at the site and
    established Departmental pollution prevention/energy efficiency
    goals \[DOE O 450.1 §5.d.(17)\].

## The provisions in this task relate to established requirements of the following DOE Policies and Department of Energy Acquisition Regulations (DEAR). {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-doe-policies-and-department-of-energy-acquisition-regulations-dear. .sub1}

-   DOE P 450.5, "The Departments and contractors' line
    organizations (a) Work together to develop ES&H performance
    objectives, measures, and expectations, . . . as well as performance
    goals and objectives of the \[Environment, Safety and Health\]
    Management System elements."

-   DOE P 450.5, "A robust, rigorous, and credible contractor
    self-assessment program linked to the DOE \[Environment, Safety and
    Health\] Management System is in place, which includes elements that
    address . . . performance measures and performance indicators . . .
    ."

-   DEAR clause 970.5223-1(d), "The \[ISM\] System shall describe how
    the contractor will establish, document, and implement
    \[environment, safety and health\] performance objectives,
    performance measures, and commitments . . . . The System shall also
    describe how the contractor will measure system effectiveness."

-   DEAR clause 970.5223-1(e), "On an annual basis, the contractor shall
    review and update . . . its \[environment, safety and health\]
    performance objectives, performance measures, and commitments . . .
    ."

Task 5 sets forth the approach for setting objectives and targets for
the significant environmental aspects. It is through the achievement of
these objectives and targets that an organization addresses its
significant aspects, including its compliance, mission, and
environmental risks. To be confident that the objectives and targets
will be effective in addressing the significant environmental aspects,
it is important that they be systematically established and periodically
reviewed and reconsidered within the management review process.

1.  Defining Objectives and Targets

Setting objectives and targets requires a clear understanding of the
exact meaning of these terms. The following paragraphs explain how the
ISMS/EMS team might apply the terms in an EMS.

EMS Objectives

Objectives describe the organization's goals for environmental
performance. The organization should set measurable (and if possible
quantified) objectives. Some objectives are quantifiable, while others
that cannot be quantified may still be measured quantitatively. For
example, the organization may set an objective to reduce pesticide usage
by 4 percent in the first year. Such a *quantified objective* is
possible because the organization is aware of its previous pesticide
usage and thus has a baseline against which it can measure improvement.

An objective to develop a plan to reduce the use of hazardous chemicals
by 20 percent through the use of less hazardous substitutes is
*measurable* even if it is not *quantifiable.* Another common example of
this relates to compliance. If the organization has achieved compliance
with a regulatory requirement, it may set its objective to maintain
compliance. The key when setting objectives is to ensure that they are
measurable whether or not they are quantifiable.

EMS Targets

Targets are specific and measurable immediate steps that the
organization can in terms of obtaining the objectives. When the
organization has set objectives, it may break them down into more
specific subordinate targets. For example, an objective may be to reduce
pesticide use by 20 percent in 2 years. Targets for this objective may
include reductions of pesticide usage by 10 percent in grounds
maintenance and by 10 percent in facility pest control.

When the objective is not quantified, targets can be used to provide
performance measures by setting dates for completion of specific tasks.
For example, if the objective is to develop a plan to reduce the use of
hazardous chemicals by 20 percent through the use of less hazardous
substitutes, the targets may define the completion date for this plan,
(i.e., within 1 year).

2.  Approach to Setting Objectives and Targets

The ISMS/EMS team should consider a variety of factors when setting
objectives and targets to ensure that the objectives and targets are
feasible and achievable. The following paragraphs describe some
well-recognized factors. However, there may be other factors specific to
the organization that the team should consider. These include any items
that the ISMS/EMS team believes may influence the effectiveness of the
objectives and targets. The pollution prevention possibilities for a
given aspect should be considered before setting objectives and targets.

## Considerations for setting objectives and targets include the following. {#considerations-for-setting-objectives-and-targets-include-the-following. .sub1}

-   Applicability of regulatory requirements, Executive Orders, and DOE
    Orders.

-   Applicability of pollution prevention opportunities.

-   Views of interested parties, such as employees, neighbors,
    environmental groups, and customers.

-   Financial, operational, and technological options available and
    feasible for the organization.

-   Organizational mission and need for continued operations.

```{=html}
<!-- -->
```
-   Direction and commitments described in the organization's
    environmental policy.

Setting Objectives and Targets

In addition, the ISMS/EMS team should consider measurability and
timeframes when setting objectives and targets. Whenever possible, the
ISMS/EMS team should set objectives and targets in quantitative terms,
with specific timeframes for accomplishment, to facilitate performance
monitoring and trends analysis. However, while measurability should
normally be specified, quantification is not a requirement. In some
cases, quantification may not be possible because there is no baseline
against which to measure performance of the environmental aspect. In
these cases, the first cycle of measurements will serve as a baseline
against which to compare future performance.

Estimated resource requirements may be set for each objective and
target. These resources include financial requirements, time needed, and
manpower resources needed for achieving the objectives and targets.

The ISMS/EMS team should list all of the objectives with detailed
descriptions, including all of the targets that make up each objective
and a detailed resource estimate and justification. This information is
necessary for assessing the ISMS/EMS. In addition, the ISMS/EMS team
should maintain a summary table to track progress toward developing
objectives and targets and to keep as a record after formalization of
the objectives and targets are. Table 9 is an example of this type of
summary table.

## TASK 6: Formalize Environmental Objectives and Targets And Develop The Environmental Management Plan  {#task-6-formalize-environmental-objectives-and-targets-and-develop-the-environmental-management-plan .H2}

The final task in Phase I is to formalize the organization's objectives
and targets. The primary decision makers (management) in the
organization must agree on the objectives and targets before they can be
formalized. Management must review the detailed descriptions of the
objectives, the resource estimates, and any other related information
necessary for it to authorize implementation of programs for achieving
the objectives and targets (see Table 9).

Once management has authorized the use of resources and the development
of programs to achieve objectives and targets, the organization can
proceed to accomplish those aims through development of an Environmental
Management Plan. The organization creates the EMP for achieving the
objectives and targets set for significant environmental aspects. These
new, modified, or existing EMPs should clearly describe any additional
actions and tasks needed to achieve the objectives and targets for the
EMS elements. For additional guidance on EMPs, see Section 5.1.1 of this
Guide.

+------+-------------+-----------+---------+----------+--------+---+---+
| **   | **          | **        | **Signi | **Obj    | **Ta   | * | * |
| Env. | Activities/ | Potential | ficance | ective** | rget** | * | * |
| Aspe | Products    | Impacts** | based** |          |        | R | A |
| ct** | /Services** |           |         |          |        | e | p |
|      |             |           | **1     |          |        | s | p |
|      |             |           | overall |          |        | o | r |
|      |             |           | scor    |          |        | u | o |
|      |             |           | e\>30** |          |        | r | v |
|      |             |           |         |          |        | c | a |
|      |             |           | **2     |          |        | e | l |
|      |             |           | reg.    |          |        | * | * |
|      |             |           | score** |          |        | * | * |
|      |             |           |         |          |        |   |   |
|      |             |           | **3     |          |        | * |   |
|      |             |           | mission |          |        | * |   |
|      |             |           | score** |          |        | ( |   |
|      |             |           |         |          |        | F |   |
|      |             |           |         |          |        | T |   |
|      |             |           |         |          |        | E |   |
|      |             |           |         |          |        | ) |   |
|      |             |           |         |          |        | * |   |
|      |             |           |         |          |        | * |   |
+------+-------------+-----------+---------+----------+--------+---+---+
| Air  | Using and   | General   | Sign    | Reduce   | C      | 0 | y |
| E    | Storing     | reduction | ificant | air      | onduct | . | e |
| miss | Chem.       | in air    | on:     | e        | PPOA   | 7 | s |
| ions | Products    | quality,  |         | missions | in a   | 5 |   |
|      | and Chem.   | and       | Reg.    |          | 1^st^  |   |   |
|      | Hazardous   | potential | Score   | Reduce   | q      |   |   |
|      | Agents      | human,    |         | number   | uarter |   |   |
|      |             | ec        |         | of       | of FY. |   |   |
|      |             | ological, |         | vi       | Report |   |   |
|      |             | and       |         | olations | r      |   |   |
|      |             | habitat   |         | for non  | esults |   |   |
|      |             | effects   |         | co       | in     |   |   |
|      |             | in the    |         | mpliance | 3^rd^  |   |   |
|      |             | locality, |         |          | q      |   |   |
|      |             | spreading |         |          | uarter |   |   |
|      |             | over a    |         |          | of FY, |   |   |
|      |             | large     |         |          | set    |   |   |
|      |             | footprint |         |          | new    |   |   |
|      |             | affecting |         |          | target |   |   |
|      |             | all media |         |          | to     |   |   |
|      |             | and       |         |          | imp    |   |   |
|      |             | biota.    |         |          | lement |   |   |
|      |             | Nonc      |         |          | P2     |   |   |
|      |             | ompliance |         |          | so     |   |   |
|      |             | with      |         |          | lution |   |   |
|      |             | a         |         |          | by     |   |   |
|      |             | pplicable |         |          | 4^th^  |   |   |
|      |             | laws/reg  |         |          | q      |   |   |
|      |             | ulations. |         |          | uarter |   |   |
|      |             |           |         |          | of the |   |   |
|      |             |           |         |          | second |   |   |
|      |             |           |         |          | year   |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | C           |           |         |          |        |   |   |
|      | onstructing |           |         |          |        |   |   |
|      | or          |           |         |          |        |   |   |
|      | Modifying   |           |         |          |        |   |   |
|      | Facilities, |           |         |          |        |   |   |
|      | Processes,  |           |         |          |        |   |   |
|      | or          |           |         |          |        |   |   |
|      | Equipment   |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | De          |           |         |          |        |   |   |
|      | activating, |           |         |          |        |   |   |
|      | Decom       |           |         |          |        |   |   |
|      | missioning, |           |         |          |        |   |   |
|      | D           |           |         |          |        |   |   |
|      | ismantling, |           |         |          |        |   |   |
|      | or Closing  |           |         |          |        |   |   |
|      | Facilities, |           |         |          |        |   |   |
|      | Equipment,  |           |         |          |        |   |   |
|      | and         |           |         |          |        |   |   |
|      | Processes   |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | M           |           |         |          |        |   |   |
|      | aintaining, |           |         |          |        |   |   |
|      | Servicing   |           |         |          |        |   |   |
|      | or          |           |         |          |        |   |   |
|      | Repairing   |           |         |          |        |   |   |
|      | Re          |           |         |          |        |   |   |
|      | frigeration |           |         |          |        |   |   |
|      | and Air     |           |         |          |        |   |   |
|      | C           |           |         |          |        |   |   |
|      | onditioning |           |         |          |        |   |   |
|      | Equipment   |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | C           |           |         |          |        |   |   |
|      | onstructing |           |         |          |        |   |   |
|      | Hazardous   |           |         |          |        |   |   |
|      | Waste Units |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Combusting  |           |         |          |        |   |   |
|      | fuel for    |           |         |          |        |   |   |
|      | heat, power |           |         |          |        |   |   |
|      | or          |           |         |          |        |   |   |
|      | electricity |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Closing     |           |         |          |        |   |   |
|      | Waste       |           |         |          |        |   |   |
|      | Management  |           |         |          |        |   |   |
|      | Units       |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
| Dis  | C           | E         | Sign    | Ensure   | Have   | 0 | y |
| turb | onstructing | cological | ificant | that     | tr     | . | e |
| ance | or          | damage,   | on:     | cultural | aining | 5 | s |
| of   | Modifying   | damage of |         | and      | p      |   |   |
| Cult | Facilities, | c         | Reg.    | hi       | rogram |   |   |
| ural | Processes,  | ulturally | Score   | storical | in     |   |   |
| Hi   | or          | and       |         | pres     | place  |   |   |
| stor | Equipment   | his       |         | ervation | within |   |   |
| ical |             | torically |         | training | 9      |   |   |
| R    |             | si        |         | is       | months |   |   |
| esou |             | gnificant |         | a        |        |   |   |
| rces |             | a         |         | vailable |        |   |   |
|      |             | rtifacts. |         | to waste |        |   |   |
|      |             | Nonc      |         | ma       |        |   |   |
|      |             | ompliance |         | nagement |        |   |   |
|      |             | with      |         | staff    |        |   |   |
|      |             | a         |         |          |        |   |   |
|      |             | pplicable |         |          |        |   |   |
|      |             | laws/reg  |         |          |        |   |   |
|      |             | ulations. |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Conducting  |           |         |          |        |   |   |
|      | Open        |           |         |          |        |   |   |
|      | Burning     |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | C           |           |         |          |        |   |   |
|      | onstructing |           |         |          |        |   |   |
|      | or          |           |         |          |        |   |   |
|      | Modifying   |           |         |          |        |   |   |
|      | Aboveground |           |         |          |        |   |   |
|      | and         |           |         |          |        |   |   |
|      | Underground |           |         |          |        |   |   |
|      | Storage     |           |         |          |        |   |   |
|      | Tanks       |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
| Rele | De          | Runoff to | Sign    | Conduct  | C      | 2 | y |
| ases | activating, | local     | ificant | PPOA of  | onduct | . | e |
| to   | Decom       | rivers    | on:     | all      | PPOA   | 0 | s |
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| stew | D           | streams   | Reg.    | tivities | 1^st^  |   |   |
| ater | ismantling, | with      | Score   | and      | q      |   |   |
| Sy   | or Closing  | species,  |         | p        | uarter |   |   |
| stem | Facilities, | habitat,  | Overall | rocesses | of FY. |   |   |
| and  | Equipment,  | and       | Score   | that     | Report |   |   |
| Gro  | and         | fisheries |         | produce  | r      |   |   |
| undw | Processes   | impacts.  |         | di       | esults |   |   |
| ater |             | Leaching  |         | scharges | in     |   |   |
|      |             | to        |         | and      | 3^rd^  |   |   |
|      |             | gr        |         | identify | q      |   |   |
|      |             | oundwater |         | oppor    | uarter |   |   |
|      |             | (         |         | tunities | of FY, |   |   |
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|      |             | and       |         | e        | new    |   |   |
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|      |             | Nonc      |         | or       | to     |   |   |
|      |             | ompliance |         | reduce   | imp    |   |   |
|      |             | with      |         | dis      | lement |   |   |
|      |             | a         |         | charges. | P2     |   |   |
|      |             | pplicable |         |          | sol    |   |   |
|      |             | laws/reg  |         |          | utions |   |   |
|      |             | ulations. |         |          | by     |   |   |
|      |             |           |         |          | 4^th^  |   |   |
|      |             |           |         |          | q      |   |   |
|      |             |           |         |          | uarter |   |   |
|      |             |           |         |          | of     |   |   |
|      |             |           |         |          | second |   |   |
|      |             |           |         |          | year.  |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Conducting  |           |         |          |        |   |   |
|      | Research    |           |         |          |        |   |   |
|      | and         |           |         |          |        |   |   |
|      | Development |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Leaks,      |           |         |          |        |   |   |
|      | Spills, and |           |         |          |        |   |   |
|      | Releases    |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
| Med  | Conducting  | E         | Sign    | Analyze  | Reduce | 0 | y |
| ical | Research    | cological | ificant | ways to  | waste  | . | e |
| W    | and         | damage,   | on:     | reduce   | gene   | 5 | s |
| aste | Development | cont      |         | waste    | ration |   |   |
| Gen  |             | amination | Reg.    | ge       | by 5%  |   |   |
| erat |             | of air,   | Score   | neration | in     |   |   |
| ion, |             | water,    |         | &        | 2      |   |   |
| Ma   |             | and soil  |         | maintain | years. |   |   |
| nage |             | with      |         | full     |        |   |   |
| ment |             | bi        |         | reg.     |        |   |   |
| and  |             | ohazards, |         | co       |        |   |   |
| Disp |             | impact to |         | mpliance |        |   |   |
| osal |             | human     |         |          |        |   |   |
|      |             | health    |         |          |        |   |   |
|      |             | and       |         |          |        |   |   |
|      |             | biota,    |         |          |        |   |   |
|      |             | waste     |         |          |        |   |   |
|      |             | ge        |         |          |        |   |   |
|      |             | neration. |         |          |        |   |   |
|      |             | Nonc      |         |          |        |   |   |
|      |             | ompliance |         |          |        |   |   |
|      |             | with      |         |          |        |   |   |
|      |             | a         |         |          |        |   |   |
|      |             | pplicable |         |          |        |   |   |
|      |             | l         |         |          |        |   |   |
|      |             | aws/regs. |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
| Rad  | Closing     | Waste     | Sign    | Analyze  | Reduce | 3 | y |
| ioac | Waste       | storage   | ificant | ways to  | waste  | . | e |
| tive | Management  | and       | on:     | reduce   | gene   | 0 | s |
| w    | Units       | disposal; |         | waste    | ration |   |   |
| aste |             | harm to   | Reg.    | ge       | by 5%  |   |   |
| ge   |             | the       | Score   | neration | in     |   |   |
| nera |             | environ.  |         |          | 2      |   |   |
| tion |             | impact to | Mission | Achieve  | years. |   |   |
|      |             | human     | Score   | full     |        |   |   |
|      |             | health    |         | re       | D      |   |   |
|      |             | and       | Overall | gulatory | evelop |   |   |
|      |             | biota;    | Score   | co       | p      |   |   |
|      |             | solid     |         | mpliance | rogram |   |   |
|      |             | waste     |         |          | to     |   |   |
|      |             | ge        |         |          | a      |   |   |
|      |             | neration. |         |          | chieve |   |   |
|      |             | Nonc      |         |          | full   |   |   |
|      |             | ompliance |         |          | comp   |   |   |
|      |             | with      |         |          | liance |   |   |
|      |             | a         |         |          | within |   |   |
|      |             | pplicable |         |          | 2      |   |   |
|      |             | l         |         |          |  years |   |   |
|      |             | aws/regs. |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Treating,   |           |         |          |        |   |   |
|      | Storing,    |           |         |          |        |   |   |
|      | Disposal of |           |         |          |        |   |   |
|      | Waste       |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Releases,   |           |         |          |        |   |   |
|      | Leaks,      |           |         |          |        |   |   |
|      | Spills,     |           |         |          |        |   |   |
|      | Releases    |           |         |          |        |   |   |
|      | from Waste  |           |         |          |        |   |   |
|      | Management  |           |         |          |        |   |   |
|      | Activities  |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+
|      | Disposition |           |         |          |        |   |   |
|      | of Excess   |           |         |          |        |   |   |
|      | Materials   |           |         |          |        |   |   |
+------+-------------+-----------+---------+----------+--------+---+---+

#  Phase II---Implementation and Operation

# Integrated Safety Management System/ Environmental Management System Documentation {#integrated-safety-management-system-environmental-management-system-documentation .H1}

![](media/image5.wmf){width="6.498611111111111in"
height="1.6208333333333333in"}

## TASK 7: Updating The Integrated Safety Management System/Environmental Management System Description {#task-7-updating-the-integrated-safety-management-systemenvironmental-management-system-description .H2}

## References {#references-3 .sub1}

## This task provides guidance on how to meet the requirements listed below. {#this-task-provides-guidance-on-how-to-meet-the-requirements-listed-below. .sub1}

-   The Contractor Requirements Document (CRD) attached to DOE O 450.1
    specifies that one of the requirements of the Order is to "update
    approved ISMS descriptions as necessary to include EMS requirements
    of this CRD. The provisions in this task relate to established
    requirements of the following Integrated Safety Management System
    (ISMS) elements.

    -   DEAR clause 970.5223-1(e), "The contractor shall submit to the
        contracting officer documentation of its \[ISM\] System for
        review and approval."

    -   ISM Guiding Principle 7, "Operations Authorization. The
        conditions and requirements to be satisfied for operations to be
        initiated and conducted shall be clearly established and agreed
        upon."

        1.  Background

DEAR 970.5223-1 requires that the ISMS be documented, and many DOE sites
have already met this requirement through the use of an ISMS
description, which the contractor prepares and DOE approves. Generally,
the ISMS description identifies existing policies, procedures, and
manuals of practice used when performing work. In addition, many
contractors have found it beneficial to provide details on the overall
ISMS philosophy or vision, the implementation mechanisms, and the
contractor's approach to integrating Environment, Safety and Health
requirements into the processes for planning and conducting work at the
site to effectively protect the workers, the public, and the
environment. Most contractors have organized their ISMS descriptions to
reflect the core functions and guiding principles of ISMS.

Section 5.d. (2) of DOE O 450.1 requires the ISMS description to be
updated, as necessary, to include the Environmental Management System
(EMS) elements required by the Order. In many cases, sites with existing
ISMSs are likely to have already addressed these EMS elements in their
ISMS descriptions.

2.  Documenting Environmental Management System Elements

Appendix B contains a list of the EMS elements required by DOE O 450.1
that the ISMS description should include. A gap analysis (see draft DOE
G 450.1-1 for a discussion of conducting a gap analysis) can determine
which EMS elements required by DOE O 450.1 are already included in the
site's existing ISMS description. The elements of an EMS and the ISMS
core functions and guiding principles are very similar (see draft DOE G
450.1-1 for a discussion of the similarities between ISMS and EMS).
Because of this compatibility between the two systems, updating the ISMS
description should be straightforward. For example, if a site's gap
analysis uncovered the need to conduct an environmental aspects
analysis, and the site conducted such an analysis, then the contractor
should update the ISMS description to include a description of this
analysis. Since analyzing environmental aspects is very similar to the
"analyze the hazards" concept in ISMS, that part of the description
should include a discussion of the environmental aspects analysis.

## TASK 8: Developing An Environmental Management System Roadmap  {#task-8-developing-an-environmental-management-system-roadmap .H2}

3.  Background

It may be useful for sites to develop a document that lists all the EMS
elements required by DOE O 450.1 and describes their location in the
ISMS description. This document can act as a checklist of EMS
requirements, and allows an auditor or other interested party to quickly
determine where all EMS elements are located or referenced in the ISMS
description. For example, this checklist might be useful to the Office
of Independent Oversight and Performance Assurance, which under the DOE
O 450.1 has the responsibility to assess implementation of the
requirements of the Order (DOE O 450.1 § 5.e.). This checklist is
referred to as the "EMS Roadmap."

4.  EMS Roadmap Template

Appendix B contains a complete EMS Roadmap template and an example
illustrating the use of this template. Although this template is not a
requirement of the Order, when the site has fully integrated the EMS
Elements into its ISMS, it should be able to provide references for all
the DOE O 450.1 requirements.

# Developing Environmental Management Programs {#developing-environmental-management-programs .H1}

![](media/image6.wmf){width="6.498611111111111in"
height="1.6277777777777778in"}

## TASK 9: Create environmental management programs  {#task-9-create-environmental-management-programs .H2}

## References {#references-4 .sub1}

## This task provides guidance on how to meet the DOE O 450.1 requirements listed below. {#this-task-provides-guidance-on-how-to-meet-the-doe-o-450.1-requirements-listed-below. .sub1}

-   The ISMS/EMS includes policies \[and\] procedures to manage,
    control, and mitigate the potential impacts of site activities with
    significant environmental impacts \[DOE O 450.1 §4.a. (2)\].

-   The ISMS/EMS includes (if applicable) conformity of DOE proposed
    actions with State Implementation Plans to attain and maintain
    national ambient air quality standards \[DOE O 450.1 §4.b. (1)(a)\].

-   The ISMS/EMS includes (if applicable) implementation of a watershed
    approach for surface-water protection \[DOE O 450.1 §4.b. (1)(b)\].

-   The ISMS/EMS includes (if applicable) implementation of a site-wide
    approach for groundwater protection \[DOE O 450.1 §4.b. (1)(c)\].

-   The ISMS/EMS includes (if applicable) protection of other natural
    resources, including biota \[DOE O 450.1 §4.b. (1)(d)\].

-   The ISMS/EMS includes development and implementation of
    cost-effective pollution prevention programs that use life-cycle
    assessment concepts and practices in determining program
    return-on-investment \[DOE O 450.1 §5.c. (4)\].

-   The ISMS/EMS includes (if applicable) protection of cultural
    resources \[DOE O 450.1 §4.b. (1)(f)\].

-   The ISMS/EMS includes (if applicable) protection of site resources
    from wildland and operational fires \[DOE O 450.1 §4.b. (1)(e)\].

-   The ISMS/EMS provides for reduction or elimination of: the
    generation of waste, the release of pollutants to the environment,
    and the use of Class I ozone-depleting substances (ODS), through
    source reduction, reuse, segregation, and recycling and by procuring
    recycled-content materials and environmentally preferable products
    and services \[DOE O 450.1 §4.b. (3)\].

-   The ISMS/EMS promotes the long-term stewardship of a site's natural
    and cultural resources throughout its operational, closure, and
    postclosure life cycle \[DOE O 450.1 §4.b. (2)\].

## The provisions in this task relate to established requirements of the following ISMS elements. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-elements.-1 .sub1}

-   ISM Guiding Principle 6, "Hazard Controls Tailored to Work Being
    Performed. Administrative and engineering controls to prevent and
    mitigate hazards shall be tailored to the work being performed and
    associated hazards."

-   Environmental management programs---environmental management
    programs \[a subset of management programs (MP) in the ISMS/EMS\]
    address the environmental goals, objectives, and targets set for
    significant environmental aspects.

    1.  Create Environmental Management Programs

At this point, the ISMS/EMS team should have identified the
organization's significant environmental aspects and established new or
modified goals, objectives and targets based on the Chapter 1, Phase I
guidance. The next task is to develop Environmental Management Programs
(EMPs) to achieve these goals, objectives and targets. Sites may
approach the creation of EMPs from different perspectives. They may
develop one for each significant environmental aspect (identified in
Chapter 1, Phase I); they may develop one for each objective and target;
they may develop them for activities that contain significant
environmental aspects; and they may even develop them for facilities
with many significant environmental aspects. Wherever possible, sites
should use existing ISMS programs to address the EMS goals, objectives
and targets. If there is no suitable program under the ISMS, then the
team should create new EMPs for that purpose. Whatever approach sites
use should suit their operations and make best use of existing programs.

EMPs should cover all EMS goals, objectives and targets set for
significant environmental aspects and that they should include the
allocation of organizational resources, the assignment of environmental
management program responsibilities for tasks, and the specification of
timelines for actions that are to be taken. It is also useful to
document other EMS elements in the EMP such as employee training,
operational controls, performance indicators, and relevant legal
requirements.

## TASK 10: Document Environmental Management Programs {#task-10-document-environmental-management-programs .H2}

The site should formally document its EMP. The EMP template, contained
in Appendix B, is an optional approach for structuring the documentation
of an EMP. A DOE site developed and used the template contained in
Appendix B. Although many sites already have well-documented management
programs, this template is useful for those sites that do not have
written programs; those sites that have documented programs but would
like to compare these programs against an alternative approach; and
those sites that have formal documented programs for most of their
goals, objectives, and targets but need to address some new ones related
to the EMS elements.

## TASK 11: Approve the Environmental Management Programs {#task-11-approve-the-environmental-management-programs .H2}

## Reference {#reference-2 .sub1}

## This task provides guidance on how to meet the DOE Order requirements listed below. {#this-task-provides-guidance-on-how-to-meet-the-doe-order-requirements-listed-below. .sub1}

-   DOE Operations/Field/Site Office Managers must "ensure that
    contractors with approved ISMS descriptions update the ISMS
    description as necessary, to include the EMS requirements of this
    Order." \[DOE O 450.1 § 5.d. (2)\]

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element.-3 .sub1}

-   DOE P 450.4, "Responsibilities must be clearly defined in documents
    appropriate to the activity. For each management mechanism employed
    to satisfy \[an environment, safety, and health\] management
    principle or function, the associated approval authority needs to be
    established. The review and approval levels may vary commensurate
    with the type of work and the hazards involved."

    1.  Review and Approval

Once completed, the EMPs should be presented to appropriate management
for review and approval. The ISMS/EMS team should incorporate
management's comments before gaining final approval. Management's
approval should be obtained before individuals are trained, new
activities designated, and resources expended.

2.  Placement of Completed Environmental Management Program Documents

The ISMS/EMS description should reference the EMPs, after their
approval.

# Developing Operational Controls  {#developing-operational-controls .H1}

![](media/image7.wmf){width="6.498611111111111in"
height="1.6270833333333334in"}

## TASK 12: Specify operational controls  {#task-12-specify-operational-controls .H2}

## References {#references-5 .sub1}

## This task provides guidance on how to meet the DOE Order requirements listed below. {#this-task-provides-guidance-on-how-to-meet-the-doe-order-requirements-listed-below.-1 .sub1}

-   The ISMS/EMS includes procedures to manage, control, and mitigate
    the potential impacts of site activities with significant
    environmental impacts \[DOE O 450.1 §4.a.(2)\].

-   The ISMS/EMS includes training to identify activities with
    significant environmental impacts \[DOE O 450.1 §4.a.(2)\].

-   The ISMS/EMS includes training to manage, control, and mitigate the
    potential impacts of site activities with significant environmental
    impacts \[DOE O 450.1 §4.a.(2)\].

-   The ISMS/EMS includes training to assess performance and implement
    corrective actions where needed \[DOE O 450.1 §4.a.(2)\].

-   The ISMS/EMS provides for obtaining, as appropriate, community
    advice relevant to aspects of "Greening the Government" Executive
    Orders, through new or existing outreach programs \[DOE O 450.1
    §5.d.(3)\].

## The provisions in this task relate to established requirements of the following ISMS elements. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-elements.-2 .sub1}

-   ISM Core Function 3, "Develop and Implement Hazard Controls: . . .
    controls to prevent/mitigate hazards are identified, the
    \[environment, safety and health\] envelope is established, and
    controls are implemented."

-   ISM Core Function 4, "Perform Work within Controls."

    1.  Specifying Operational Controls

As mentioned in Step 5, operational controls are an important element
for managing EMS goals, objectives, and targets. Operational controls
are applied to specific activities or processes managed by the EMP and
can fall into two categories: (1) engineering controls and
(2) administrative controls.

Engineering controls intervene mechanically to avoid a potential
incident. A simple example is using a funnel to reduce the chance of oil
spills. Administrative controls include procedural approaches to
activities, such as training employees on the procedure for filling fuel
tanks. Frequently, sites use administrative and engineering controls in
combination, in which case the procedure incorporates the funnel as one
of the mechanical controls workers are to follow when filling fuel
tanks. The system documentation should include these operational
controls.

Sites should apply operational controls to the activities, products, and
services that give rise to significant environmental aspects. For
example, *energy use* may have been designated as a significant
environmental aspect. One of the activities that could cause this aspect
may be *office work*. While it may not be feasible to set operational
controls for office work as a whole, individual operational controls can
be set for each contributing *source* such as computers, the office
kitchen, and office heating, all of which are component parts of office
work. Sites implement operational controls as integral parts of the
EMPs. Another example is an objective to reduce hazardous waste produced
by a laboratory. In this case, the site could apply operational controls
to specific tasks, processes, or analytical techniques.

Wherever possible, sites should use existing operational controls to
control the occurrence of specific aspects identified in Phase I.
However, it is possible that sites will need to develop new operational
controls to address specific operations and activities that have
significant environmental aspects as identified in Phase I. The ISMS/EMS
description should reference these new operational controls. The
operational control template, provided in Appendix B, is an approach
that many organizations have used effectively to document their
operational controls.

## TASK 13: Approve operational controls  {#task-13-approve-operational-controls .H2}

## Reference {#reference-3 .sub1}

## This task provides guidance on how to meet the DOE Order requirements listed below. {#this-task-provides-guidance-on-how-to-meet-the-doe-order-requirements-listed-below.-2 .sub1}

-   DOE Operations/Field/Site Office Manager must "ensure that
    contractors with approved ISMS descriptions update the ISMS
    description as necessary, to include the EMS requirements of this
    Order." \[DOE O 450.1 §5.d.(2)\]

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element.-4 .sub1}

-   DOE P 450.4, "Responsibilities must be clearly defined in documents
    appropriate to the activity. For each management mechanism employed
    to satisfy \[an environment, safety and health\] management
    principle or function, the associated approval authority needs to be
    established. The review and approval levels may vary commensurate
    with the type of work and the hazards involved."

    1.  Review and Approval

Once completed, an operational control should be sent to appropriate
management for review and approval. The ISMS/EMS team should incorporate
management's comments before gaining its approval. The team should
obtain management's approval before individual training, designation of
new activities, and resource expenditures occur.

2.  Placement of Completed Operational Controls

The ISMS/EMS description should reference operational controls after
their approval.

# Develop Integrated Safety Management System/Environmental Management System Procedures {#develop-integrated-safety-management-systemenvironmental-management-system-procedures .H1}

![](media/image8.wmf){width="6.498611111111111in"
height="1.6270833333333334in"}

## TASK 14: Establish Integrated Safety Management System/ Environmental Management System Procedures {#task-14-establish-integrated-safety-management-system-environmental-management-system-procedures .H2}

## References {#references-6 .sub1}

## This task provides guidance on how to meet the DOE Order requirements listed below. {#this-task-provides-guidance-on-how-to-meet-the-doe-order-requirements-listed-below.-3 .sub1}

-   The ISMS/EMS includes policies, procedures to assess performance
    \[DOE O 450.1 §4.a.(2)\].

-   Contractor ES&H self-assessment programs within the framework of DOE
    P 450.5 are established and continue to be effective \[DOE O 450.1
    §5.d.(16)\].

-   The ISMS/EMS ensures the early identification of, and appropriate
    response to, potential adverse environmental impacts associated with
    DOE operations, including, as appropriate, preoperational
    characterization and assessment and effluent and surveillance
    monitoring \[DOE O 450.1 §4.b.(4)\].

-   The ISMS/EMS provides for the conduct of environmental monitoring,
    as appropriate, to support the site's ISMS, to detect, characterize,
    and respond to releases from DOE activities \[DOE O 450.1
    §5.d.(14)\].

-   The ISMS/EMS provides for the conduct of environmental monitoring,
    as appropriate, to assess impacts, to estimate dispersal patterns in
    the environment, to characterize the pathways of exposure to members
    of the public, and to characterize the exposures and doses to
    individuals, and to the population \[DOE O 450.1 §5.d.(14)\].

-   The ISMS/EMS provides for the conduct of environmental monitoring,
    as appropriate, to evaluate the potential impacts to the biota in
    the vicinity of the DOE activity \[DOE O 450.1 §5.d.(14)\].

-   The ISMS/EMS provides for the implementation of the analytical work
    supporting environmental monitoring using a consistent system for
    collecting, assessing, and documenting environmental data of known
    and documented quality \[DOE O 450.1 §5.d.(15)(a)\].

-   The ISMS/EMS provides for the implementation of the analytical work
    supporting environmental monitoring using a validated and consistent
    approach for sampling and analysis of radionuclide samples to ensure
    laboratory data meet program-specific needs and requirements within
    the framework of a performance-based approach for analytical
    laboratory work \[DOE O 450.1 §5.d.(15)(b)\].

-   The ISMS/EMS provides for the implementation of the analytical work
    supporting environmental monitoring using an integrated sampling
    approach to avoid duplicative data collection \[DOE O 450.1
    §5.d.(15)(c)\].

## The provisions in this task relate to established requirements of the following ISMS elements. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-elements.-3 .sub1}

-   DOE P 450.4, "\[Environment, Safety and Health\] Mechanisms define
    how the core \[environment, safety and health\] management functions
    are performed. The mechanisms may vary from facility to facility and
    from activity to activity based on the hazards and the work being
    performed and may include: contractor policies, procedures and
    documents . . . established to implement \[environment, safety and
    health\] management . . . ."

-   ISM Core Function 3, "Develop and Implement Hazard Controls: . . .
    controls to prevent/mitigate hazards are identified, the
    \[environment, safety and health\] envelope is established, and
    controls are implemented."

-   ISM Core Function 4, "Perform Work within Controls."

    1.  Integrated Safety Management System/Environmental Management
        System Procedures

Standard operating procedures are an essential element of any management
system. Sites should document these procedures, as well as other
procedures that are repeatedly carried out in the ISMS/EMS. By
documenting all procedures, sites improve the likelihood that they are
carried out consistently and reliably. Table 10 of Appendix B lists all
the procedures required by DOE O 450.1, as well as the procedures that
are recommended. Sites should consider documenting all these procedures.

2.  The Role of Integrated Safety Management System/Environmental
    Management System Procedures

Standard Operating Procedures include two types of procedures: (1) those
that directly address environmental issues, such as the procedure for
identifying environmental aspects, the procedure for identifying legal
and other requirements and the procedure for setting goals, objectives,
and targets, and (2) those that are administrative, such as record
keeping and document control. Many DOE sites may already have most of
these procedures. Standard operating procedures enable information to
flow to individuals at the relevant functions and levels of the
organization. This provides them with the knowledge and expertise to
manage the day-to-day environmental impacts of their work activities and
to support the organization's ISMS/EMS goals, objectives and targets.
ISMS/EMS procedures also promote reliable and appropriate information
flows that allow the execution of emergency response plans, the checking
of system status and progress, the correction of nonconformances, the
upgrading of training levels and competence, the implementation of
programs and operational controls to achieve goals, objectives and
targets, and the proper involvement and intervention of the
organization's appropriate management. The EMS procedures discussed here
can be used to help maintain the effectiveness of the EMS elements
within an ISMS/EMS over the long-term.

3.  Keeping Procedures Simple

ISMS/EMS procedures should be simple to implement and execute on an
ongoing basis. The major goal of achieving reliability in the management
of environmental, safety and health (ES&H) exposures can be jeopardized
by complicated or unnecessarily prescriptive procedures. This is
particularly important in using the ISMS/EMS to integrate ES&H programs
into the organization's total operations and not just those of the ES&H
staff.

## TASK 15: Documenting Integrated Safety Management System/Environmental Management System Procedures {#task-15-documenting-integrated-safety-management-systemenvironmental-management-system-procedures .H2}

4.  Integrated Safety Management System /Environmental Management System
    Procedures

In many cases, DOE sites will already have the majority of these
procedures in place, including records management, document control,
emergency preparedness and response, and training as part of the ISMS or
as part of the site general management system. Usually it is possible to
incorporate the appropriate EMS requirements directly into these
existing procedures. Therefore, ISMS/EMS teams should identify
potentially applicable existing procedures wherever possible and then
use them as the basis for satisfying any additional EMS requirements. If
there is no existing procedure, the site should develop a new procedure
to fulfill the requirement of the ISMS/EMS.

5.  Implementing Integrated Safety Management System/Environmental
    Management System Procedures

The ISMS/EMS team should coordinates the preparation of the ISMS/EMS
procedures. The task of writing or upgrading each procedure will fall
either to the environmental staff or to functional staff members
responsible for that particular activity in the organization. For
example, the administrative staff at the site may modify or write
*records management* and *document control* procedures to conform to the
expanded ISMS/EMS requirements. Responsibility for modifying the
*emergency preparedness and response* procedure may be a task for the
emergency response and occupational health and safety staff with input
from the environmental staff on the potential environmental consequences
and the proper manner to respond to them. On the other hand, those
assigned to environmental duties are more likely to write the
environmental aspects identification procedure. Planning and
coordinating the responsibilities for writing the ISMS/EMS procedures
constitute a major effort. Sites should designate an individual to serve
as the ISMS/EMS coordinator to coordinate the procedure drafting
process. He or she should ensure that, to the greatest extent possible,
such procedures do not duplicate existing site or ISMS procedures. The
goal, rather, is to promote the total integration of EMS elements into
the ISMS/EMS.

Although some specific functions play a greater role in the
implementation of the ISMS/EMS, all employees have some role to play.
This is because all job functions within the organization are likely to
have the opportunity to interact with the ISMS/EMS at some point.
Therefore, all employees should be able to implement those procedures
that specifically apply to their job functions.

## TASK 16: Approve Integrated Safety Management System/ Environmental Management System procedures {#task-16-approve-integrated-safety-management-system-environmental-management-system-procedures .H2}

## References {#references-7 .sub1}

## This task fulfills several DOE Order requirements listed below. {#this-task-fulfills-several-doe-order-requirements-listed-below.-2 .sub1}

-   The ISMS/EMS provides for the evaluation of programs for compliance
    with applicable requirements \[DOE O 450.1 §4.a. (1)(c)\].

-   The ISMS/EMS provides for the evaluation of programs for public
    health and environmental protection \[DOE O 450.1 §4.a. (1)(a)\].

-   The ISMS/EMS provides for the evaluation of programs for pollution
    prevention \[DOE O 450.1 §4.a. (1)(b)\].

-   The assessment of ISMS/EMS implementation is a component of the
    implementation of DOE P 450.5 Line Environment, Safety and Health
    Oversight (DOE O 450.1 §5.b.).

-   The ISMS/EMS includes policies and procedures to implement
    corrective actions where needed \[DOE O 450.1 §4.a. (2)\].

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element.-5 .sub1}

-   DOE P 450.4, "Responsibilities must be clearly defined in documents
    appropriate to the activity. For each management mechanism employed
    to satisfy \[an environment, safety and health\] management
    principle or function, the associated approval authority needs to be
    established. The review and approval levels may vary commensurate
    with the type of work and the hazards involved."

    1.  Review and Approval

It is essential that appropriate management review and approve new or
adapted procedures. Once the ISMS/EMS procedures are complete, the
ISMS/EMS team sends it to appropriate management for review, and
incorporates management's comments before obtaining final approval. The
procedure must obtain management approval before its implementation at
the site.

## TASK 17: Implement Integrated Safety Management System /Environmental Management System procedures {#task-17-implement-integrated-safety-management-system-environmental-management-system-procedures .H2}

## References {#references-8 .sub1}

## The provisions in this task relate to established requirements of the following ISMS elements. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-elements.-4 .sub1}

-   ISM Core Function 4, "Perform Work within Controls."

-   ISM Guiding Principle 3, "Competence Commensurate with
    Responsibilities. Personnel shall possess the experience, knowledge,
    skills, and abilities that are necessary to discharge their
    responsibilities."

    1.  Background

The site should implement ISMS/EMS procedures at all levels and
functions and integrate the procedures into the existing site system, so
all site employees can follow them. Procedures should reflect,
therefore, actions occurring on the ground at the site. It is also
essential that all employees in the organization be able to easily
follow the procedures that apply to their job functions.

2.  Training

Training is an important part of the implementation of the ISMS/EMS
procedures. The site should make all employees aware of procedures
through general awareness training, which should detail, in particular,
any changes made to existing procedures.

3.  Responsibility for Maintaining Records

The implementation of procedures creates records in the ISMS/EMS. These
include training records, audit reports, minutes of meetings, records of
equipment calibration, reports of compliance status, lists of aspects
and legal requirements, communication memorandums, measurements of
outcomes, and so on. Each procedure should specify the basis for
producing such records. At the time of implementation, all applicable
personnel must be aware of who is responsible for creating, managing,
labeling, collecting, and storing these records.

4.  Maintaining Procedures

Over time, it will be necessary to make changes to the procedures as
employees identify elements for improvement or new record needs are
identified as site operations evolve. In particular, it is likely that
many changes will be necessary soon after the initial implementation of
procedures. The first use of a procedure often reveals many areas for
its improvement. Following this initial modification, the site should
update procedures periodically as operations and systems evolve. This is
part of the continual improvement process of the ISMS/EMS. As these
updates occur, the ISMS/EMS coordinator should ensure---

-   procedures are controlled in accordance with the site's document
    control procedure and only the latest authorized version of each
    procedure is in circulation for use by employees,

-   the revision date is displayed on each procedure, and

-   employees are aware of any changes and have access to the latest
    authorized versions.

    1.  Accessibility

        Because the purpose of procedures is to standardize common
        activities that occur in the ISMS/EMS to ensure their
        performance to the same high standard, employees should have
        easy access to the procedures. The accessibility of a procedure
        to employees is the result of several factors described below.

Physical Accessibility

The ISMS/EMS relies heavily on the participation and contributions of
line functions. Physical accessibility ensures that employees can obtain
the procedures they are supposed to be following. Physical accessibility
is more than merely permitting the retrieval of a document from a file
drawer; it requires that access to the document be convenient,
immediate, and encouraged.

## Employees need to know that documents exist and their locations, and that they have ready and easy access to them. This may necessitate posters at work sites that point to the location of applicable procedures and that encourage workers to retrieve them.  {#employees-need-to-know-that-documents-exist-and-their-locations-and-that-they-have-ready-and-easy-access-to-them.-this-may-necessitate-posters-at-work-sites-that-point-to-the-location-of-applicable-procedures-and-that-encourage-workers-to-retrieve-them. .sub-heading}

##  {#section-1 .sub-heading}

Conceptual Access

Employees must also have conceptual access to the specific requirements
contained in procedures. This means that, in addition to being able to
locate the procedures, they must be able to understand the concepts
contained within them. Procedures should be simple and easy to follow
for their primary users.

Operational Access

Operational access concerns whether employees can realistically apply
the procedure in a real situation. The question to answer here is
whether the procedural requirements consider the work area conditions
and culture, and whether employees can apply them under those
conditions. The internal ISMS/EMS assessment and employee feedback will
eventually answer this question.

#  Phase III---Checking and Corrective Action

# Establishing the ISMS/EMS Assessment Program {#establishing-the-ismsems-assessment-program .H1}

![](media/image9.wmf){width="6.498611111111111in"
height="1.6277777777777778in"}

## TASK 18: Establish the ISMS/EMS Assessment Program  {#task-18-establish-the-ismsems-assessment-program .H2}

## References {#references-9 .sub1}

## This task fulfills requirements in several DOE Directives listed below. {#this-task-fulfills-requirements-in-several-doe-directives-listed-below. .sub1}

-   The Integrated Safety Management System/Environmental Management
    System (ISMS/EMS) provides for the evaluation of programs for public
    health and environmental protection, pollution prevention, and
    compliance with applicable requirements \[DOE O 450.1 §4.a.(1)\].

-   Contractor ES&H self-assessment programs within the framework of
    U.S. Department of Energy (DOE) P 450.5 are established and continue
    to be effective \[DOE O 450.1 §5.d.(16)(c)\].

-   The ISMS/EMS includes policies and procedures to assess performance
    and implement corrective actions where needed \[DOE O 450.1
    (4.a.(2)\].

-   Draft DOE Policy on Oversight, DOE P 226.1, and draft DOE Notice on
    Oversight Policy, DOE N 226.1, provide for the need for
    self-assessments, for internal independent assessments, and for
    independent oversight reviews.

## The provisions in this task also relate to requirements in the following ISMS elements. {#the-provisions-in-this-task-also-relate-to-requirements-in-the-following-isms-elements. .sub1}

-   ISM Core Function 5, "Provide Feedback and Continuous Improvement: .
    . . line and independent oversight is conducted . . . ."

-   DOE P 450.5, "A robust, rigorous, and credible contractor
    self-assessment program linked to the DOE \[Environment, Safety and
    Health\] Management System is in place, which includes elements that
    address . . . line and independent evaluations."

-   DOE P 450.5, DOE field elements conduct "a periodic, value-added
    appraisal of sufficient frequency and duration to confirm the
    contractor's \[safe and environmentally sound\] performance of work
    and the effectiveness of the \[contractor's\] self-assessment
    program."

-   DOE G 450.4-1B, Chapter III, discusses assessing an ISMS, and
    Chapter IV discusses maintaining and sustaining an approved ISMS.

    1.  Background and Purpose

Self-assessment activities range from informal, to formal and
structured. The purpose of this section of the Guide is to provide
guidance on conducting formal self-assessments. Normally an organization
with an appropriate degree of independence from the activity being
reviewed conducts these assessments.

The assessment described here (referred to as assessment or ISMS/EMS
assessment) is a structured, formal self-assessment used to evaluate a
site's ISMS/EMS. For example, some DOE sites have already established
Internal Independent Review Boards that conduct these types of
assessments of the site's ISMS. These existing programs should be used
to satisfy the DOE O 450.1 requirement that a site's ISMS/EMS include
policies and procedures to assess performance and implement corrective
actions.

2.  The Assessment Program

DOE P 450.5 and DOE O 414.1A require a rigorous and credible contractor
self-assessment program linked to the organization's ISMS that address
the following.

1.  Performance measures and performance indicators.

2.  Line evaluations and independent evaluations.

3.  Compliance with applicable requirements.

4.  Data collection, analysis, and corrective actions.

5.  Feedback and performance improvement.

Conducting an assessment is not a one-time activity. To ensure
assessment performance and management in an organized fashion with
regularity, efficiency, and effectiveness, sites should have an
"Assessment Program." The ongoing activities associated with providing
for, preparing for, and carrying out the assessments makes up the site's
"Assessment Program." The Assessment Program should also include the
establishment of assessment procedures, protocols, and criteria that
verify the effectiveness of both the individual elements of the system
and of the system in its entirety (see Figure 1). The Assessment Program
should comprise the site's provisions and arrangements for ongoing
assessments as well as its systematic approach for preparing for and
planning each ISMS/EMS assessment. Other elements of the Assessment
Program should include---

-   communicating the Assessment Program to relevant parties;

-   coordinating and scheduling assessments and other assessment program
    activities;

-   establishing and maintaining a process for the initial training of
    the assessment team and for the ongoing evaluation of its training
    needs;

-   ensuring the selection of assessment teams;

-   providing necessary resources to the assessment teams;

-   ensuring the conduct of assessments in accordance with the
    Assessment Program;

-   ensuring the control of records of the assessment activities;

-   ensuring review and approval of assessment reports, and ensuring
    their distribution to the site being assessed and other specified
    parties; and

-   ensuring assessment followup, when applicable.

    1.  Assessment Concepts

The ISMS/EMS assessments should be carried out in order to determine
whether or not the ISMS/EMS conforms to requirements established by DOE
O 450.1 and whether the site has properly implemented and maintained it.
Based on this presentation of information during the management review,
the organization should consider actions or changes to the ISMS/EMS
system such as the following.

-   Corrective actions for functional environment, safety, and health
    program integration issues.

-   Corrective actions to improve ISMS/EMS implementation and
    effectiveness.

-   Performance measures for the next year.

-   Any changes required in the assessment focus or criteria.

-   Any changes, if required, to an ISMS/EMS description document.

-   Impacts of any changes to laws, regulations, and directives.

-   Any changes to the level of resources applied to the ISMS/EMS.

> Figure 1. Sample assessment program reflecting how concepts of the
> plan-do-check-act cycle are incorporated in it.

![](media/image10.wmf){width="6.469444444444444in"
height="6.572222222222222in"}

The organization should determine whether the ISMS/EMS system and
performance objectives, performance measures, and commitments require
modification, update, or revision in the scheduled review and approval
process. (See DOE G 450.4.-1B.)

The ISMS/EMS assessment is a review of system implementation and system
strength. It should provide senior management with information
concerning the ISMS/EMS and enable managers to identify priority areas
for improvement. Information gained from the ISMS/EMS assessment should
be reviewed during the management review described in Phase IV. It may
be helpful to clarify the meaning and intent of the ISMS/EMS assessment
by stating what it is and what it is not.

-   The ISMS/EMS assessment is a documented process that provides a
    snapshot view of the ISMS/EMS status at a point in time from which
    the organization can continue to improve.

-   It is more than a walk-through (that may or may not be documented)
    by various individuals within an organization. It is a formal
    process that uses established criteria for conducting the assessment
    and individuals within the organization who are trained to conduct
    the assessments.

-   It is not primarily a regulatory compliance assessment, so it need
    not verify the organization's compliance with applicable laws and
    regulations. It can, however, make use of information on the
    compliance status of the organization to ascertain whether the
    management system is succeeding in addressing compliance and
    performance goals the organization has set.

-   It is not, by itself, a performance check to ascertain whether the
    site is meeting performance goals or making progress toward meeting
    them (see below). As with compliance, the assessment team may use
    information on whether the site is meeting performance goals or
    progressing to evaluate whether the system needs further improvement
    in certain areas to ensure progress towards meeting certain
    performance goals. The assessment team should use information on
    both performance attainments and compliance as indicators of whether
    the elements of the ISMS/EMS require improvement.

-   It is not a management review since that is a distinct and separate
    item of the ISMS/EMS that the organization's management conducts
    (see Phase IV). The ISMS/EMS assessment should not duplicate or
    obviate management's determination of the suitability, adequacy, and
    effectiveness of the ISMS/EMS. The ISMS/EMS assessment should,
    however, determine whether the process established for the
    management review is sufficiently rigorous to allow the
    organization's management to make the determinations of suitability,
    adequacy, and effectiveness.

## TASK 19: Plan the Assessment {#task-19-plan-the-assessment .H2}

## References {#references-10 .sub1}

## This task fulfills requirements in several DOE directives listed below. {#this-task-fulfills-requirements-in-several-doe-directives-listed-below.-1 .sub1}

-   The ISMS/EMS provides for the evaluation of programs for public
    health and environmental protection, pollution prevention, and
    compliance with applicable requirements \[DOE O 450.1 §4.a.(1)\].

-   Contractor ES&H self-assessment programs within the framework of DOE
    P 450.5 are established and continue to be effective \[DOE O 450.1
    §5.d.(16)(c)\].

-   The ISMS/EMS includes policies and procedures to assess performance
    and implement corrective actions where needed \[DOE O 450.1
    (4.a.(2)\].

-   The draft DOE Policy on Oversight , DOE P 226.1, and the draft
    Notice on Oversight Policy, DOE N 226.1, provide for
    self‑assessments, internal independent assessments, and independent
    oversight reviews.

## The provisions in this task also relate to requirements in the following ISMS elements. {#the-provisions-in-this-task-also-relate-to-requirements-in-the-following-isms-elements.-1 .sub1}

-   ISMS Core Function 5, "Provide Feedback and Continuous Improvement:
    . . . line and independent oversight is conducted . . . ."

-   DOE P 450.5, "A robust, rigorous, and credible contractor
    self-assessment program linked to the DOE \[Environment, Safety and
    Health\] Management System is in place, which includes elements that
    address . . . line and independent evaluations."

-   DOE P 450.5, DOE field elements conduct "a periodic, value-added
    appraisal of sufficient frequency and duration to confirm the
    contractor's \[safe and environmentally sound\] performance of work
    and the effectiveness of the \[contractor's\] self-assessment
    program."

-   DOE G 450.4-1B, Chapter III on assessing ISMSs and Chapter IV on
    maintaining and sustaining approved ISMSs.

Section 8.2.1 discusses audit principles that are relevant and
appropriate for ISMS/EMS assessments (see Figure 2). Also included are
best-practice descriptions of the implementation of these principles.
While it is likely that sites already use many of these principles and
practices in their assessments, the discussion below aims to provide
additional insights and opportunities for sites to enhance or adapt
their existing assessment programs.

1.  Basic Principles

The same principles used in the auditing arena are applicable to
conducting an assessment. A number of auditing principles ensure that
assessments are effective and reliable so as to support management
policies and to provide data that personnel can use to improve
performance. Adherence to these principles also ensures that assessment
team members working independently from one another can reach relevant
and consistent assessment conclusions.

## The following are two key principles of auditing. {#the-following-are-two-key-principles-of-auditing. .sub1}

-   *Impartiality*---This is the basis for maintaining objectivity of
    the assessment conclusions. (Assessment team members should be
    independent of the activity being assessed and be free from bias and
    conflict of interest. Assessment team members should maintain an
    objective state of mind throughout the assessment process to ensure
    that the assessment findings and conclusions will be based only on
    the collected evidence.)

-   *Evidence-based approach*---This is the method for reaching reliable
    and reproducible assessment conclusions in a systematic assessment
    process.

    1.  Conducting the Assessment

Planning

Typically, the assessment process should proceed in stages, including
preparation, communication, coordination, execution, documentation, and
closure. Figure 2, *ISMS/EMS assessment process flow chart*, illustrates
this process. The assessment team may also use existing site assessment
processes to accomplish this task*.*

1.  *Initiating the assessment plan*---The site should assemble an
    assessment team to develop a plan to conduct the assessment.
    Initially, the team should ensure that it has all the information
    necessary to write the plan. It can use a checklist to ensure the
    availability of the necessary information for the assessment plan.
    (See sample ISMS/EMS Internal Assessment Preparation Checklist,
    Appendix C). See other notes on page refs.

2.  *Completing the assessment plan*---Appendix C, provides a sample
    assessment plan, including instructions regarding how to use the
    plan. This or a similar form can help in the planning of an
    assessment.

## TASK 20: Conduct Onsite Assessment Activities  {#task-20-conduct-onsite-assessment-activities .H2}

## References {#references-11 .sub1}

## This task fulfills requirements in several DOE Directives listed below. {#this-task-fulfills-requirements-in-several-doe-directives-listed-below.-2 .sub1}

-   The ISMS/EMS provides for the evaluation of programs for public
    health and environmental protection, pollution prevention, and
    compliance with applicable requirements \[DOE O 450.1 §4.a.(1)\].

-   Contractor ES&H self-assessment programs within the framework of DOE
    P 450.5 are established and continue to be effective \[DOE O 450.1
    §5.d.(16)(c)\].

-   The ISMS/EMS includes policies and procedures to assess performance
    and implement corrective actions where needed \[DOE O 450.1
    (4.a.(2)\].

-   The draft DOE Policy on oversight, DOE P 226.1, and draft Notice on
    oversight policy, DOE N 226.1, provide for self-assessments,
    internal independent assessments, and independent oversight reviews.

## The provisions in this task also relate to requirements in the following ISMS elements. {#the-provisions-in-this-task-also-relate-to-requirements-in-the-following-isms-elements.-2 .sub1}

-   ISM Core Function 5, "Provide Feedback and Continuous Improvement: .
    . . line and independent oversight is conducted . . . ."

-   DOE P 450.5, "A robust, rigorous, and credible contractor
    self-assessment program linked to the DOE \[Environment, Safety and
    Health\] Management System is in place, which includes elements that
    address . . . line and independent evaluations."

-   DOE P 450.5, "A robust, rigorous, and credible contractor
    self-assessment program linked to the DOE \[Environment, Safety and
    Health\] Management System is in place, which includes elements that
    address . . . compliance with applicable requirements . . . ."

-   DOE P 450.5, DOE field elements conduct "a periodic, value-added
    appraisal of sufficient frequency and duration to confirm the
    contractor's \[safe and environmentally sound\] performance of work
    and the effectiveness of the \[contractor's\] self-assessment
    program."

-   DOE G 450.4-1B, Chapter III, on assessing ISMSs, and Chapter IV, on
    maintaining and sustaining approved ISMSs.

Figure 2. ISMS/EMS assessment process flow chart.

![](media/image11.wmf){width="5.785416666666666in"
height="6.416666666666667in"}

Having completed preparations for the assessment, the assessment team
should be ready to conduct the assessment. The team does the assessment
primarily through the analyses of documentation and by observing and
interviewing employees. The planning phase of the assessment should have
identified areas for priority, appropriate staff to be interviewed, and
records to be analyzed. The assessment team should communicate these
requirements to the organization being assessed prior to the initial
meeting so that documents, records, employees to be interviewed, and any
required safety items can be available in a timely and convenient
manner. The tasks below describe an approach and key stages for
conducting onsite assessments. The team can also use existing site
assessment processes to accomplish this task.

1.  **Conduct opening meeting.** The assessment team should conduct an
    opening meeting with appropriate management of the organization it
    is assessing (e.g., the ISMS/EMS coordinator, facility manager, and
    other staff if necessary). The following should be included in the
    opening meeting.

-   Proper introductions (initiate an attendance record).

-   Review of the scope, objectives, and assessment plan and agreement
    on the timetable.

-   Short summary of the methods and procedures that will be used.

-   Establishment of the official communication link between the team
    and management of the organization to be assessed.

-   Confirmation that the resources and facilities needed by the team
    are available.

-   Confirmation of the time and date of the closing meeting (request
    that the organization's senior management be present).

-   Encouragement of the active participation of the organization's
    personnel during the assessment.

-   Review of relevant site safety and emergency procedures the team
    will follow during the assessment.

1.  **Collect information.** Assessment team members collect information
    in any of three ways: by reviewing documents and records, by
    interviewing employees, and by observing employees and systems in
    operation.

2.  **Assess observations against criteria.** Appendix C contains an
    example of the assessment criteria used by a DOE facility. Another
    example is provided in Table 10. The assessment team can use this
    questionnaire to determine---

-   root causes of system failures (for example, inadequate training may
    be the root cause for repeated failure of an operational control),

-   areas that conform and have best practices, and

-   areas where further improvements can be made.

3.  **Verify against the assessment criteria.**

*4.1 Findings---*The assessment team must classify each of the findings
either during the assessment or at its completion (see example in Table
10). The team can classify findings in any way that the assessed
organization finds convenient. For example, findings may fall into four
classifications.

-   A = In Conformance

-   B = Critical: Omission of an ISMS/EMS requirement or failure to
    implement an EMS Element of the ISMS/EMS.

-   C = Serious: A significant number of minor nonconformances against
    any one ISMS/EMS requirement.

-   D = Minor: A single nonconformance of a system requirement.

*4.2 Recommendations*---In addition to findings, the assessment team may
identify areas where improvements could be made but that do not warrant
a finding (see example in Table 10). Such improvements might include---

-   alternative approaches that are recognized as best in class,

-   approaches that enhance organizational mission, and

-   approaches that reduce cost.

*4.3 Comments*---The assessment team may include comments in connection
with findings, best practices, and opportunities to improve (see example
in Table 10).

4.  **Prepare** **Assessment Summary Report.** In preparation for the
    assessment's closing meeting, the assessment team should prepare a
    *Findings and Summary Report* that may include---

-   A summary of the assessment (overall, areas of strength, areas of
    weakness) and recommendations and

-   A list of all the findings, including---

    -   the finding category,

    -   finding description, and

    -   finding location.

The sample Assessment Findings Summary Table and the sample ISMS/EMS
Assessment Summary Report Template in Appendix C identify options for
presenting the summary report and findings.

5.  **Prepare Corrective Action Report*. ***The assessment team may also
    prepare a Corrective Action Report (CAR) as shown in Table 11 for
    each finding. These CARs, if developed, should be delivered to the
    assessed organization during the closing meeting.

6.  **Conduct closing meeting.** A closing meeting should be conducted
    to complete the assessment to allow the assessment team members and
    the assessed organization to exchange information and lessons
    learned as well as to agree on followup actions to address findings.
    Closeout meetings may include the following---

-   a discussion by the team leader of his/her overall impression of the
    assessment,

-   a presentation that explains that the assessment team's findings are
    based on a sampling of evidence,

-   a presentation by each assessment team member of his/her individual
    findings and recommendations,

-   distribution of copies of the CARs to the assessed organization's
    management,

-   an opportunity for the assessed organization's representatives to
    ask questions regarding findings and recommendations,

-   an explanation of the how the team will conduct the visit to check
    on corrective and preventive action progress,

-   a discussion that explains to whom the team will forward draft
    assessment reports, and

-   a discussion between the assessment team and the assessed
    organization regarding the findings. \[Need to be sure there is a
    common understanding between the parties (may need to agree to
    disagree) on matters in contention.\]

7.  **Prepare final assessment report**. The assessment report is the
    official record of the assessment that the team should provide to
    the assessed organization's senior management. It is a key source of
    information on the general health of the ISMS/EMS and should be an
    important part of the subsequent management review.

Following a specified time period (e.g., a week), during which time
corrective actions and associated CARs (see Table 11) can be generated,
the assessment team should deliver the final assessment report. This
report should identify all findings, including those that the
organization has corrected, as well as best practices, opportunities to
improve, and any recommendations or comments. In most cases, final
assessment reports can be very similar to summary reports, except that
they represent a formal record of the assessment outcomes.

The assessment team leader is usually responsible for the preparation
and contents of the assessment report, which should provide a complete,
accurate, concise, and clear record of the assessment and may include or
refer to the following:

-   assessment objectives;

-   assessment scope, particularly the identification of the
    organizational and functional units or processes assessed and the
    time period covered;

-   identification of the assessment team leader and members;

-   dates and places where the onsite assessment activities were
    conducted;

-   assessment criteria;

-   assessment findings;

-   assessment conclusions;

-   assessment plan;

-   summary of the assessment process, including uncertainty and/or
    obstacles encountered that can decrease the reliability of the
    assessment conclusions;

-   confirmation that the assessment objectives have been accomplished
    within the assessment scope in accordance with the assessment plan;

-   areas not covered, although within the assessment scope;

-   unresolved, diverging opinions between the assessment team and the
    assessed organization;

-   recommendations for improvement, if specified in the assessment
    objectives;

-   agreed-to followup action plans, if any;

-   statement of the confidential nature of the contents; and

-   distribution list for the assessment report.

8.  **Conduct** **corrective actions*. ***Following the closeout
    meeting, the assessed unit should correct all findings and complete
    a corrective action report similar to that shown in Table 11. This
    corrective action report contains fields where the unit can describe
    actions it took to address the findings, including---

-   root cause analysis,

-   interim actions,

-   corrective actions, and

-   preventative actions.

Table 10. Sample Portion of the Assessment Questionnaire

\[The following table contains a portion of the ISMS/EMS Assessment
Questionnaire, which lists system requirements and root causes of
nonconformances in the organization's system (the full questionnaire is
included in Appendix C).\]

  ---------------------------------------------------------------------------------------------------------------------------------
  **[Questions to address     **[Finding]{.mark}**   **[Best              **[Improvement            **[Comment]{.mark}/evidence**
  implementation of system                           practice]{.mark}**   opportunities]{.mark}**   
  requirements and root                                                                             
  causes of existing                                                                                
  nonconformances]{.mark}**                                                                         
  --------------------------- ---------------------- -------------------- ------------------------- -------------------------------
  1\. Questions to determine                                                                        
  implementation and                                                                                
  effectiveness of the ES&H                                                                         
  Policy                                                                                            

  *System Requirements:*                                                                            

  Does the organization have  [A]{.mark}                                                            
  an ES&H Policy?                                                                                   

  Does the policy reflect the [A]{.mark}                                                            
  organization's values?                                                                            

  Does the policy provide a   [A]{.mark}             []{.mark}            []{.mark}                 []{.mark}
  framework for setting and                                                                         
  reviewing environmental                                                                           
  objectives and targets at                                                                         
  all levels within the                                                                             
  organization?                                                                                     

  Does the policy include a   [A]{.mark}                                                            []{.mark}
  commitment to the                                                                                 
  prevention of pollution?                                                                          

  Does the policy include     [C]{.mark}                                                            [Policy does not explicitly
  commitments to continual                                                                          demand continual improvement
  improvement and compliance                                                                        but does describe the principle
  with relevant laws and                                                                            for it.]{.mark}
  other requirements                                                                                
  applicable to the                                                                                 
  organization?                                                                                     

  Is the policy appropriate   [A]{.mark}                                                            []{.mark}
  to the nature, scale, and                                                                         
  environmental impacts of                                                                          
  the organization's                                                                                
  activities, products or                                                                           
  services?                                                                                         

  Is the policy communicated  [C]{.mark}                                  [X]{.mark}                [Policy not widely displayed.
  to all employees and made                                                                         General employees were
  available to the public?                                                                          unfamiliar with it and did not
                                                                                                    apply it to daily
                                                                                                    activities.]{.mark}

  Is it clear that the policy [A]{.mark}                                                            
  has senior management's                                                                           
  endorsement and commitment?                                                                       

  2\. Questions to determine                                                                        
  root causes for existing                                                                          
  nonconformities                                                                                   

  Was senior management                              [X]{.mark}           []{.mark}                 [Meeting minutes show that
  involved in crafting the                                                                          management was principally
  policy?                                                                                           involved in crafting the
                                                                                                    policy]{.mark}

  Are there any obvious                              []{.mark}            []{.mark}                 []{.mark}
  inconsistencies between the                                                                       
  policy commitments and                                                                            
  organizational practices?                                                                         

  Do employees believe that                          []{.mark}            [X]{.mark}                [Employees did not believe that
  management is sincere in                                                                          management understands that
  its commitment to the                                                                             application of the policy is
  ISMS/EMS?                                                                                         important]{.mark}

  Does management believe                                                                           
  that systematic                                                                                   
  environmental, safety and                                                                         
  health management will                                                                            
  improve the quality and                                                                           
  success of this                                                                                   
  organization?                                                                                     

  Is there evidence that                                                                            
  sufficient resources have                                                                         
  been allocated to the                                                                             
  ISMS/EMS implementation                                                                           
  over a sustained period?                                                                          
  ---------------------------------------------------------------------------------------------------------------------------------

Findings may fall into four classifications according to their
seriousness. The classifications are as follows.

> A = In Conformance.
>
> B = Critical: Omission of an ISMS/EMS requirement or failure to
> implement an EMS Element of the ISMS/EMS.
>
> C = Serious: A significant number of minor nonconformances against any
> one system requirement.
>
> D = Minor: A single nonconformance of a system requirement.
>
> X = Indicates where a best practices or improvement opportunity was
> found.

Table 11. Sample ISMS/EMS Corrective Action Report Template

*(This is a sample of the CAR report template included in Appendix C.)*

![](media/image12.wmf){width="6.499305555555556in"
height="7.280555555555556in"}

#  Phase IV---Management Review and System Maintenance

# Develop the management review process {#develop-the-management-review-process .H1}

![](media/image13.wmf){width="6.498611111111111in"
height="1.6270833333333334in"}

## TASK 21: Prepare for the Management Review {#task-21-prepare-for-the-management-review .H2}

## References {#references-12 .sub1}

## This task fulfills several DOE Order requirements listed below. {#this-task-fulfills-several-doe-order-requirements-listed-below.-3 .sub1}

-   The Integrated Safety Management System/Environmental Management
    System (ISMS/EMS) provides for the evaluation of programs for public
    health and environmental protection, pollution prevention, and
    compliance with applicable requirements \[DOE O 450.1 §4.a.(1)\].

-   The ISMS/EMS includes policies and procedures to assess performance
    and implement corrective actions where needed \[DOE O 450.1
    §4.a.(2)\].

-   The ISMS/EMS include annual reviews of and updates (when
    appropriate) the site's measurable environmental goals, objectives,
    and targets \[DOE O 450.1 §4.a.(3)\].

-   ISMS/EMS implementation is assessed as a component of the
    implementation of DOE P 450.5, *Line Environment, Safety and Health
    Oversight* (DOE O 450.1 §5.b.).

-   Contractor ES&H performance objectives, performance measures, and
    commitments are reviewed through the annual ISM review process
    \[established pursuant to DEAR 970.5223-1 (e)\] \[DOE O 450.1
    §5.d.(17)\].

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element.-6 .sub1}

-   DOE G 450.4-1A states that the annual ISMS review "is the
    integration of numerous system-related activities in a manner that
    assists management in assuring that work is performed . . . in a
    manner that protects the public, workers, and environment from harm"
    (p. 92).

    1.  Background

When applied to a site's ISMS/EMS, the term "Management Review" refers
to the periodic evaluation of the ISMS/EMS by senior management (i.e.,
managers who have the authority to make decisions for the site or
facility). This review completes the ISMS/EMS plan-do-check-act cycle
and allows management to ascertain whether the ISMS/EMS continues to be
*suitable, adequate,* and *effective* for its intended purposes. The
management review is not the same as the assessment process discussed in
Phase III. However, senior managers conducting the management review
should consider the results of the site's assessment.

For DOE sites, the concepts and principles of the management review are
already addressed by many areas of the ISMS developed under DOE P 450.4,
particularly the requirement for an annual review of ISMS performance.
For example, the management review aligns with ISMS core principle 5 for
feedback and improvement; specifically, that sites "should have a
process for management to consider and dispose of recommendations for
improvement." DEAR, 48 CFR 970.5223-1 (d) and (e) also contain
provisions for a review which specify that, "dates for submittal,
discussions and revisions to the system will be established by the
contracting officer . . . . On an annual basis, the contractor shall
review and update, for DOE approval, its safety performance objectives,
performance measures, and commitments." This task further reinforces the
current requirement that "for the purpose of this clause, safety
encompasses the environment . . . including pollution prevention and
waste minimization." The management review, therefore, should serve to
identify any gaps or enhancement opportunities for the existing ISMS as
well as for the integrated ISMS/EMS.

The primary goal of management review should be to ensure that the
ISMS/EMS continues to be *suitable, adequate,* and *effective for its
intended purposes*. The review accomplishes this by involving the
members of the organization who have the authority to make needed
changes to ensure the effectiveness of the system. The very first
management review is usually conducted soon after the completion of
corrective actions that follow the first assessment. Subsequent reviews
are conducted on a scheduled basis or sooner if circumstances warrant
management's attention. Other important purposes of the management
review are to---

-   ensure that senior management stays involved in the ISMS/EMS;

-   give the ISMS/EMS visibility within the organization; and

-   allow senior management to set the environmental, safety, and health
    ethic for the organization and give guidance and direction for
    continual improvement of the system.

    1.  Importance of Senior Management Involvement in the Management
        Review

During the management review, senior managers should assess whether they
are satisfied with the outcomes of the ISMS/EMS and whether they should
make midcourse adjustments to bring the system back on track. In short,
the management review process allows senior managers of the organization
to---

-   assess the existing ISMS/EMS,

-   evaluate whether changes are necessary, and

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-   give direction and/or resources for any actions necessary to make
    the changes.

The importance of senior management involvement in the ISMS/EMS extends
beyond the ability to authorize resources for continual improvement. The
management review is an opportunity for the active and visible
involvement of senior management in the ISMS/EMS and, thereby
invigorates employee involvement and commitment through their
leadership.

1.  Coordinating the Management Review

The periodic ISMS/EMS management review should include the assessment of
a appropriate of information relating to the performance of the
ISMS/EMS. For example, management should review all continuing core
expectations (CCEs) described by DOE G 450.1-1B for both safety and
environment.

The ISMS/EMS coordinator should organize, schedule, and manage the
management review. He or she should collect, analyze, and assemble
pertinent information to present managers with the current status of
ISMS/EMS. The ISMS/EMS coordinator should ensure that---

-   the review meeting date is set,

-   all the necessary managers are able to participate in the review,

-   there is coordination among those presenting information during the
    review,

-   the minutes of the review have management approval,

-   management reaches decisions on whether to update the ISMS/EMS to
    maintain its effectiveness and compliance with DOE O 450.1 and DOE P
    450.4,

-   specific management decisions regarding actions, including
    allocation or reallocation of resources as a result of the review,
    begin, and

-   there is proper execution of decisions, including specific actions
    and resource allocations authorized by management, following the
    review.

    1.  Management Review Participants

Participants in the management review should include the senior
management (e.g., site managers, facility managers), the ISMS/EMS
coordinator, appropriate members of the ISMS/EMS team, P2 managers, and
other individuals with ISMS/EMS responsibilities (e.g., internal
assessors, other ISMS/EMS representatives).

## TASK 22: Conduct the Management Review {#task-22-conduct-the-management-review .H2}

## References {#references-13 .sub1}

## This task fulfills several DOE Order requirements listed below. {#this-task-fulfills-several-doe-order-requirements-listed-below.-4 .sub1}

-   The ISMS/EMS provides for the evaluation of programs for public
    health and environmental protection, pollution prevention, and
    compliance with applicable requirements \[DOE O 450.1 §4.a.(1)\].

-   The ISMS/EMS includes policies and procedures to assess performance
    \[DOE O 450.1 §4.a.(2)\].

-   The ISMS/EMS includes annual reviews and updates (when appropriate)
    the site's measurable environmental goals, objectives, and targets
    \[DOE O 450.1 §4.a.(3)\].

-   ISMS/EMS implementation is assessed as a component of the
    implementation of DOE P 450.5, *Line Environment, Safety and Health
    Oversight* (DOE O 450.1 §5.b.).

-   Contractor ES&H performance objectives, performance measures, and
    commitments are reviewed through the annual ISM review process
    \[established pursuant to DEAR 970.5223-1 (e)\] \[DOE O 450.1
    §5.d.(17)\].

## The provisions in this task relate to established requirements of the following ISMS element. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-element.-7 .sub1}

-   DOE G 450.4-1A states that the annual ISMS review "is the
    integration of numerous system-related activities in a manner that
    assists management in assuring that work is performed . . . in a
    manner that protects the public, workers, and environment from harm"
    (p. 92).

    1.  Background

In addition to fulfilling the requirements set forth in DEAR Clause
970.5223-1 that require contractors to update their environment, safety
and health (ES&H) performance objectives, measures, and commitments on
an annual basis, the management review is an opportunity for management
to confirm that it is satisfied with the performance of the ISMS/EMS.
This includes the achievement of goals set for the ISMS/EMS, and its
alignment with the organization's mission and commitments. In effect,
management should ask whether the ISMS/EMS continues to be suitable,
adequate, and effective for the DOE site in question.

Senior managers should be given all relevant information to enable them
to make accurate and sound judgments regarding ISMS/EMS implementation.
All information needed to assess the conformance of the ISMS/EMS with
DOE P 450.4 and DOE O 450.1 as well as any other objectives set by the
site should be collected, consolidated, analyzed, and communicated. As
discussed above, this is typically one of the responsibilities of the
ISMS/EMS coordinator (or individual who leads the ISMS/EMS team).
Information for the management reviews may come from the following
sources.

-   Assessments

DOE P 450.5 and DOE O 414.1A require a rigorous and credible contractor
assessment program with elements that address performance measures and
indicators, line and independent evaluations, compliance with applicable
requirements, data collection, analysis and corrective actions, and
feedback and performance improvement. These assessments should cover
ISMS and EMS elements alike and are a key source of information for the
management review. Detailed discussion of the role of the assessments
for maintaining the effectiveness and legitimacy of the ISMS/EMS was
covered earlier in Phase III.

-   Monitoring and measurement results

Data collected through ongoing system monitoring and measurement,
including ISMS/EMS programs, processes, activities, and controls, are
another key source of information for the management review. This
information relates to the achievement of objectives and targets, the
status of operational controls, the maintenance of regulatory
compliance, and other parameters that are overseen to ensure that the
ISMS/EMS remains effective.

-   Occurrence reports

Information contained in occurrence reports, especially the root causes
of an incident, are a good source of information for the management
review.

-   Corrective actions

Actions taken to correct deficiencies in the ISMS/EMS are a rich source
of information on the day-to-day health of the ISMS/EMS. The data
available from this source include---

-   the status of training (both awareness training and competence
    training);

-   the currency of regulatory and other requirements in the ISMS/EMS;

-   the identification of new significant aspects;

-   the implementation of new environmental management programs (EMPs);

-   compliance with the schedule for internal ISMS/EMS assessments; and

-   the assignment of responsibility and accountability for ISMS/EMS
    implementation, etc.

    1.  Decisions Made in the Management Review

Senior management should make specific decisions during the management
review or immediately thereafter. They may wish to consider the
following questions.

-   Is the ISMS/EMS still *suitable, adequate, and effective* for the
    organization?

-   Based on an assessment of these three characteristics, does the
    ISMS/EMS need changes?

-   If it needs changes (see box below), what actions and what resources
    are needed for those changes?

-   Who should be directed to oversee the implementation of those
    changes?

-   When does management want an update on the status and effect of the
    changes?

***Suitability:*** Refers to the nature of the ISMS/EMS and whether it
continues to be appropriate to the organization. For example, if a
site's mission changes, as in the case of a site moving to closure
status, then many of the programs and procedures established for ongoing
operation may no longer be suitable to control risks under the site's
new mission. Other approaches to the ISMS/EMS relevant to this area
would need to be considered.

***Adequacy:*** Refers to the sufficiency of the arrangements for the
ISMS/EMS. For example, if the resources allocated to management programs
are not sufficient to achieve the objectives and targets set for them,
then the ISMS/EMS may have inadequate support. If new employees do not
receive timely awareness or competence training before they begin their
assigned tasks, then the ISMS/EMS is inadequate with respect to the
training element.

***Effectiveness:*** Refers to the system's progress in accomplishing
the objectives and targets set for the ISMS/EMS. If progress is slower
than expected or if operational controls fail more often than is
expected or acceptable, then the system may be ineffective for its
intended purposes. Because the organization sets its own objectives and
targets, analyzing an ISMS/EMS's effectiveness should help management
evaluate success in achieving its own objectives and targets. In other
words, effectiveness is a relative term depending on what the
organization sets out for itself. The only exception to this is
regulatory compliance. If the organization fails to maintain regulatory
compliance, management may consider the ISMS/EMS ineffective regardless
of whether other objectives and targets are being achieved.

1.  Documenting the Management Review

The annual review and update of the ISMS/EMS should be documented. DOE G
450.4 describes this documentation in detail. The following are some of
the documentation requirements, including those in DOE O 450.1.

-   Contractor's performance against the previous year's safety and
    environmental commitments.

-   Contractor's commitments designed to achieve safety and
    environmental performance objectives and measures for the upcoming
    fiscal year.

-   Commitment of resources necessary to meet environment, safety and
    health program minimum requirements.

In addition to documenting the above outcomes of the annual management
review process, other details of the review, including the following,
should be recorded.

-   Names and functions of all participants.

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-   Copies of the presentations and other information.

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-   Decisions on the system's suitability, adequacy, and effectiveness.

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-   Decisions on changes desired for the system.

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-   Management directions for actions to be taken and resources to be
    applied.

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-   Expected timeline for achieving changes and the date of any future
    review.

    1.  Followup to the Management Review

Implementation of the changes identified in the management review should
occur as directed. Management should clearly assign responsibility for
coordinating updates or implementation of new programs. Following the
management review, management should ensure that there are sufficient
resources to carry out revisions to the ISMS/EMS. Ensuring that there
are sufficient resources aligns closely with ISMS guiding principle 4
"balanced priorities," also provided for in sections (d) and (e) of DEAR
Clause 970.5223-1. Identification of resources necessary for
environment, safety and health programs should be a part of the DOE
annual budget guidance and direction.

# Develop a Plan to Keep the ISMS/EMS Updated {#develop-a-plan-to-keep-the-ismsems-updated .H1}

![](media/image14.wmf){width="6.498611111111111in"
height="1.6277777777777778in"}

## TASK 23: Keeping the ISMS/EMS Updated  {#task-23-keeping-the-ismsems-updated .H2}

## References {#references-14 .sub1}

## The provisions in this task relate to established requirements of the following ISMS elements. {#the-provisions-in-this-task-relate-to-established-requirements-of-the-following-isms-elements.-5 .sub1}

-   DOE P 450.5, "A robust, rigorous, and credible contractor
    self-assessment program linked to the DOE \[Environment, Safety and
    Health\] Management System is in place, which includes elements that
    address . . . data collection, analysis, and corrective actions;
    \[and\] continuous feedback and performance improvement."

-   DOE P 450.5, "The Department's and contractors' line organizations
    ... work together to develop a high level of performance assurance
    which results in improved environment, safety and health
    performance."

-   DOE G 450.4-1A, Chapter IV, on keeping approved ISMSs effective
    through continuous improvement actions.

    1.  Background

Changes in regulations, site mission, site operations, budget
allocations, or customer needs will all cause changes in activities and
operations, which in turn may have safety and environmental
consequences. In some cases, it is sufficient to update the ISMS/EMS
annually to remain current and relevant to the site. However, other
changes such as regulatory amendments or new operations can occur at any
time during the year and need continual updates to the ISMS/EMS. In
particular DEAR, 48 CFR 970.5215-3, requires 1) compliance with
applicable laws, regulations, and DOE Directives; 2) implementation of
and adherence to the contractor's Safety Management System; and 3)
accomplishment of annual contractor environment, safety and health
performance commitments. The suggestions below describe how the
organization can update the ISMS/EMS to remain relevant to the
organization. (Keeping the ISMS/EMS updated is also discussed in Step 9,
above, under Management Review).

2.  Environmental Aspects

DOE O 450.1 section 4.a(2) states that the ISMS includes policies and
procedures to identify activities with significant environmental
impacts. Most sites probably address this requirement under the ISMS
Core Function 3, to identify and analyze hazards, which include
environmental hazards also referred to as environmental aspects (see
Phase I). The organization should periodically revise the procedure by
which it identifies its environmental aspects and sets improvement
objectives for those that are significant to reflect change in
regulations, mission focus, and site operations. One approach to meet
the need to maintain updated environmental aspects and safety hazards is
to execute the procedure for Identifying Significant Environmental
Aspects and Safety Hazards on a periodic basis. Another potential
practice is to update the list of significant environmental aspects on
an ongoing basis by subjecting each new activity, product, or service to
an up-front evaluation to ascertain whether it includes an environmental
aspect and whether that aspect meets a significance threshold that makes
it a significant environmental aspect. This approach will keep the
ISMS/EMS up-to-date and relevant, and will allow the organization to
address significant environmental aspects as they appear.

3.  Legal and Other Requirements

DOE O 450.1 §4.a.(1) requires that ISMS/EMS provides for the systematic
planning of programs for compliance with applicable requirements. This
recognizes that as State and Federal regulations change, it is critical
that sites update their programs and procedures for compliance. Phase II
of this Guide discusses the development of a formal procedure for
identifying legal and other requirements based on the existing site
procedure. This procedure should ensure that there is ongoing monitoring
of new legal and other requirements, as well as assessment of new
activities, products, and services to evaluate whether any legal
requirements apply to them. This approach captures applicable
information when a new requirement appears or the organization initiates
a new activity, product, or service. In addition to addressing legal and
other requirements on an ongoing basis, it is useful to conduct periodic
reviews of the organization's requirements to determine if any new
requirements apply and if any of those being addressed are out of date.
This periodic assessment can occur in conjunction with the management
review.

4.  Objectives and Targets

A fundamental element of the ISMS/EMS is the establishment of
"measurable environmental goals, objectives, and targets" \[DOE O 450.1
§4.a.(3)\]. These objectives and targets will not remain static. The
site may want to update its existing objectives and targets because it
has been accomplished them and desires new ones, or because management
directs changes based on the results of the management review, or
because new regulations, operations, or changing site mission require
revisions to these objectives and targets.

When the organization reaches an objective or target, it can set new
ones at higher levels or it can decide to maintain the level that it has
reached as long as that level satisfies regulatory requirements.

An organization normally resets or reconfirms objectives and targets in
conjunction with its management review. Management has the
responsibility to review the ISMS/EMS periodically and make
determinations for reconfirming or setting new objectives and targets.
Therefore, organizations find it convenient to reevaluate their
objectives and targets during the management review. Another opportunity
to establish or revise the site's goals, objectives, and targets occurs
with the identification of a new safety hazard or environmental aspect
(possibly as a result of regulatory changes or new operations).

5.  Environmental Management Programs

EMPs are implemented to achieve environmental objectives and targets.
Any time an objective or target for the ISMS/EMS changes or a new one is
set, the EMP that is associated with it should also reflect appropriate
changes. A new objective and target for a newly introduced significant
environmental aspect may require a new EMP.

In addition, sites should update EMPs so that the information within
them reflects ISMS/EMS activities as they are implemented on the ground.
Changes in management programs may occur on an ongoing basis due to
reassigned program responsibilities, updated training, refined
operational controls, or completed tasks.

If sites do not constantly review EMPs against the results of their
actual implementation, within a very short time period the written
program and the implemented program may become inconsistent.

6.  Training

Training is an ongoing activity. All new employees should receive
ISMS/EMS awareness training. Sites should require new employees who will
work in areas that have significant environmental aspects to demonstrate
appropriate competency based on their education, experience, or
training. Existing employees should receive periodic refresher training
for both awareness and competency in relevant areas of expertise. The
ISMS/EMS training procedure should provide for both awareness and
competency training and for refresher training.

7.  Operational Controls

Sites should establish operational controls for those activities,
products, or services that exhibit significant environmental aspects.
They are synonymous with the ISMS Core Function 4, to develop and
implement operational controls to prevent or mitigate hazards. If a new
activity, product, or service exhibits a new environmental aspect or
safety hazard, then the site should establish appropriate operational
controls to ensure that the aspect is addressed.

If the management review finds any existing operational controls to be
inappropriate or insufficient, then the site should develop and
implement new ones. The management review may also mandate revisions to
operational controls. Changes to operational controls may be necessary
because new operations may require different controls. In some cases,
the site might have automated controls that had been based on the use of
human resources. In many instances, regulations mandate operational
controls, so that a change in regulation may also trigger a change in
the required operational controls. When a site revises operational
controls, it is important that it also updates documentation related to
the controls to reflect the operational controls as they are actually
implemented by the organization.

8.  Resources for the Environmental Management System

The ISMS/EMS cannot succeed without appropriate resources; this is
recognized by ISMS Guiding Principles 4 "balanced priorities," as well
as sections (d) and (e) of DEAR Clause 970.5223-1 and by DOE O 450.1 §§
5.c.(2), 5.d.(7). As mentioned earlier, this allocation of resources
coincides with and is responsive to the DOE budget guidance and
direction. In some cases, unforeseen expenses may require allocations of
additional resources to continue progress toward the site's ISMS/EMS
objectives and targets.

9.  Occurrence Identification and Corrective Actions

The site should devote the ISMS/EMS procedure for occurrence
identification and corrective actions to making changes in the ISMS/EMS
to fix problems found during the normal course of operation. These
reflect ISMS Core Function 5, feedback and continuous improvements, as
well as several areas in DOE O 450.1, including the implementation of
corrective actions where needed \[DOE O 450.1 §4.a.(2)\]. Reporting and
addressing identified nonconformances of the ISMS/EMS should be in
accordance with this procedure. In addressing nonconformances, the site
should take both corrective and preventive actions to mitigate the
effects of the nonconformance and guard against the occurrence of
similar nonconformances. In effect, this procedure provides a mechanism
for the constant maintenance of the ISMS/EMS and is likely to generate a
considerable number of changes on an ongoing basis. It is also prudent
to periodically assess the effectiveness of the approach used to
identify, correct, and document nonconformances.

10. Developing a Formal Maintenance Schedule

The site/facility personnel may find it valuable to develop a formal
documented schedule of the various ISMS/EMS elements that require
updates and maintenance. The sample schedule illustrated in Table 12
contains some suggestions for ensuring updates for certain EMS elements
of the ISMS. Sites can use this example as a framework for developing a
comprehensive ISMS/EMS schedule. A brief explanation of the schedule
described in Table 12 follows.

-   The schedule is divided into 12 columns, one for each month of the
    year; it is based on a 1-year cycle (12 months).

-   The far left column contains the eight EMS elements the site should
    keep up-to-date (numbered 1 through 8).

-   A checkmark in a column to the right of one of these eight elements
    signifies that the element should be assessed that month to
    determine if it is current with the organization's operations.
    Please note that that the site should assess legal requirements and
    environmental aspects on an ongoing basis. For example, a regulatory
    revision should be incorporated into the ISMS/EMS as soon as
    possible. Similarly, a new activity, product, or service at the
    organization should be assessed to determine if it contains any
    significant aspects. The flow arrows for these elements (1 and 2)
    indicate what the ISMS/EMS team should do if there is a new
    regulation or new activity, product, or service. Figure 3 is a flow
    chart that illustrates the process of identifying any new legal
    requirements that may have an impact on an existing environmental
    aspect.

-   The schedule sets objectives and targets (3) and resource
    allotment (4) for assessment as part of the management review (month
    12).

-   Following the management review, it may be necessary to update
    environmental management programs, operational controls, records,
    and training programs by integrating the findings of the review so
    that the ISMS/EMS continues to be suitable, adequate, and effective.

<table style="width:100%;">
<colgroup>
<col style="width: 9%" />
<col style="width: 30%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2">Table 12. Example. Suggested Schedule for Maintaining
and Updating Required and Important Selected Elements of the
ISMS/EMS.</td>
<td><blockquote>
<p><strong>January</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>February</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>March</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>April</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>May</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>June</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>July</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>August</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>September</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>October</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>November</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>December</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td></td>
<td><strong>MONTH</strong></td>
<td><strong>1</strong></td>
<td><strong>2</strong></td>
<td><strong>3</strong></td>
<td><strong>4</strong></td>
<td><strong>5</strong></td>
<td><strong>6</strong></td>
<td><strong>7</strong></td>
<td><strong>8</strong></td>
<td><strong>9</strong></td>
<td><strong>10</strong></td>
<td><strong>11</strong></td>
<td><strong>12</strong></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p><strong>1.</strong> Identify any new legal or other requirement that
applies to an existing environmental aspect</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="14"></td>
</tr>
<tr class="odd">
<td> </td>
<td><blockquote>
<p><em>Integrate into environmental management programs</em></p>
</blockquote></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td colspan="14"></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p><strong>2.</strong> Identify any new activities, products or services
occurring at the organization</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="14"><h2 id="section-2"> </h2></td>
</tr>
<tr class="odd">
<td> </td>
<td><blockquote>
<p><em>Identify significant aspects</em></p>
</blockquote></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td><blockquote>
<p><em>Set objectives and targets</em></p>
</blockquote></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td><blockquote>
<p><em>Develop environmental management programs</em></p>
</blockquote></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td><blockquote>
<p><em>Assess in audit</em></p>
</blockquote></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p><strong>3.</strong> Assess relevance of current objectives and
targets</p>
</blockquote></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><blockquote>
<p><strong>4.</strong> Assess the appropriateness of current resource
allocation</p>
</blockquote></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p><strong>5.</strong> Asses need to update current environmental
management programs</p>
</blockquote></td>
<td></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td colspan="2"><blockquote>
<p><strong>6.</strong> Assess current operational controls for
effectiveness at controlling specific operations</p>
</blockquote></td>
<td></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p><strong>7.</strong> Update list of records to generate</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><blockquote>
<p><strong>8.</strong> Assess effectiveness of the current employee
training program</p>
</blockquote></td>
<td></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</tbody>
</table>

> Figure 3. Identifying legal and other requirements and new activities,
> products, and services that are\
> incorporated into the ISMS/EMS.

## ![](media/image15.wmf) {#section-3 .sub-heading}

# APPENDIX A ADDITIONAL GUIDANCE DOCUMENTS {#appendix-a-additional-guidance-documents .App1}

**ADDITIONAL GUIDANCE DOCUMENTS**

### Clean Air Act General Conformity {#clean-air-act-general-conformity .Sub2}

1.  Clean Air Act General Conformity Requirements and National
    Environmental Policy Act (NEPA) Process, (April, 2000),
    <http://www.eh.doe.gov/nepa/tools/guidance/caaguidance.pdf>

```{=html}
<!-- -->
```
2.  EH-41 Analysis of EPA's Rule Requiring that Federal Actions Conform
    to State Implementation Plans, (November, 1999),
    <http://homer.ornl.gov/oepa/guidance/caa/conform/pdf>

3.  Attainment Status, <http://homer.ornl.gov/oepa/data/naaqs.cfm>

4.  "Determining Conformity of General Federal Actions to State or
    Federal Implementation Plans; Final Rule 58 FR 63214, November 30,
    1993, <http://www.epa.gov/ttn/oarpg/conform/genconf_00001.pdf>.

5.  EPA General Conformity Guidance: Questions and Answers, (July 3,
    1994), <http://www.epa.gov/ttn/oarpg/conform/gogqa_71394.pdf>.

6.  General Conformity Regulations,
    <http://www.epa.gov/ttn/oarpg/genconformity.html>.

7.  Compliance with the General Conformity Regulations, Information
    Brief, (March, 2003),
    http://www.eh.doe.gov/oepa.guidance/caa/conformbrf.pdf.

### Watershed Approach for Surface-Water Protection {#watershed-approach-for-surface-water-protection .Sub2}

1.  Unified Federal Policy for a Watershed Approach to Federal Land and
    Resource Management, October 18, 2000,
    http://www.cleanwater.gov/ufp.

### Groundwater Protection {#groundwater-protection .Sub2}

1.  Technical Impracticability Decisions for Ground Water at CERLCA
    Response Action and RCRA Corrective Action Sites (DOE/EH-413/9814),
    (August 1998), <http://www.eh.doe.gov/oepa>/guidance

2.  RCRA Ground Water Assessment Plans and Annual Ground Water Quality
    Assessment Reports at Interim Status Facilities (DOE
    EH-413-069/0396), (March 1996),
    <http://www.eh.doe.gov/oepa/guidance>

3.  Guide to Ground Water Remediation at CERCLA Response Action and RCRA
    Corrective Action Sites (DOE/EH-0505), (October 1995),
    <http://www.eh.doe.gov/oepa/guidance>

4.  Department of Energy (DOE) Response to the Inspector General's
    Recommendations on Groundwater Monitoring Programs at DOE Sites,
    (September 3, 2003), <http://www.eh.doe.gov/oepa/guidance>

5.  Final Directive on the Use of Monitored Natural Attenuation at
    Superfund, RCRA Corrective Action, and Underground Storage Tank
    Sites, (June 9, 1999), <http://www.eh.doe.gov/oepa/guidance>

6.  Monitored Natural Attenuation in Environmental Restoration,
    (February 17, 1999), <http://www.eh.doe.gov/oepa/guidance>

7.  Ground Water Presumptive Response Strategy, (January 28, 1997),
    <http://www.eh.doe.gov/oepa/guidance>

### Biota {#biota .Sub2}

1.  RESRAD-Biota Code, DOE Biota Dose Assessment Committee, (BDAC),
    <http://homer.ornl.gov/oepa/public/bdac>

2.  A Graded Approach for Evaluating Radiation Doses to Aquatic and
    Terrestrial Biota (DOE-STD-1153-2002),
    <http://homer.ornl.gov/oepa/public/bdac>

3.  RESRAD-Biota: A Tool for Implementing a Graded Approach to Biota
    Dose Evaluation, Users Guide, Version 1, Interagency Steering
    Committee on Radiation Standards (ISCORS) Technical Report 2004-02,
    DOE Report Number DOE/EH-0676 (January 2004).

### Wildland Fire Management {#wildland-fire-management .Sub2}

1.  Wildland Fire Management Program for Use with DOE O 450.1,
    Environmental Protection Program (DOE G 450.1-9) draft issued
    October 24, 2003, for review and use.

2.  Secretarial Memorandum (Fire Management Program), 2001 Federal
    Wildland Fire Management Policy, (May 11, 2001).

### Cultural Resources Management {#cultural-resources-management .Sub2}

1.  Department of Energy Management of Cultural Resources, DOE P 141.1

2.  Environmental Guidelines for the Development of Cultural Resource
    Management Plans (DOE/EH-051, August 1995),
    <http://www.eh.doe.gov/oepa>

3.  Draft Environmental Guidelines for Development of Cultural Resource
    Management Plans-Update, DOE G 450.1-3

### Long-Term Stewardship {#long-term-stewardship .Sub2}

1.  Long-Term Stewardship Web Page, <http://lts.apps.em.doe.gov/>.

###  {#section-4 .Sub2}

### Pollution Prevention {#pollution-prevention .Sub2}

1.  Secretarial Memorandum, "Pollution Prevention and Energy Efficiency
    Leadership Goals for Fiscal Year 2000 and Beyond," November 12,
    1999.

2.  Pollution Prevention Web Site, <http://www.eh.doe.gov/p2>.
    Environmental Quality Systems

    **Environmental Quality Systems**

    1.  Uniform Federal Policy for Implementing Environmental Quality
        Systems: Evaluating, Assessing and Documenting Environmental
        Data Collection/Use and Technology Programs, (DOE/EH-0667,
        January, 2003) <http://www.spa.gov/swerffrr/library/data.htm>

    2.  Information Brief at http://www.eh.doe.gov/oepa

    3.  Multi-Agency Radiological Surveys and Site Investigation Manual
        (MARSSIM), Revision 1, August 2000, June 2001 Update,
        <http://www.epa.gov/radiation/marssim/obtain.htm>

    4.  Information Brief at <http://www.eh.doe.gov/oepa>

    5.  Multi-Agency Radiological Laboratory Analytical Protocols
        (MARLAP), August 2001, http://www.eml.doe.gov/marlap

# APPENDIX B EMS ROADMAP TEMPLATES {#appendix-b-ems-roadmap-templates .App1}

**CONTENTS**

B.1 ELEMENTS OF AN ISMS/EMS B-1

B.1.1 DEFINITION OF AN EMS B-1

B.1.2 Planning B-1

B.1.3 Implementation and Operation B-3

B.1.4 Checking and Corrective Action B-4

B.1.5 Management Review B-5

B.2 EMS Roadmap Templates B-6

B.2.1 Creating an EMS Roadmap B-6

B.2.2 EMS Roadmap Template B-6

B.3 Environmental Management Programs Template B-12

B.3.1 Documenting Environmental Management Programs B-12

B.4 Operational Controls Template B-20

B.4.1 Documenting Operational Controls B-20

B.4.2 Completing the Body of the Operational Controls Template (Table 7)
B-20

B.5 Documenting Integrated Safety Management System/Environmental
Management System Procedures B-26

B.5.1 Using the Procedure Templates B-28

**TABLES**

1\. EMS Roadmap Example B-6

2\. EMS Roadmap Template B-7

3\. Example of Completed Environmental Management Program Template B-12

4\. Example of Performance Indicators (Field 6) B-16

5\. Example of Completed Field 10 (Structure, Authorities,
Responsibilities) B-18

6\. Competence B-20

7\. Completed Operational Controls Template B-21

8\. Examples of Operational Controls That Might Be Designated for a
Variety of sources B-24

9\. Examples of Maintenance Plans That Might Be Developed for a variety
of Operational Controls B-24

10\. EMS Element Procedures Required by DOE O 450.1 B-26

11 Example of ISMS/EMS Procedure for Determining Goals, Objectives,\
and Targets B-29

B.1 ELEMENTS OF AN ISMS/EMS

The four principal elements of an ISMS/EMS, along with their
corresponding subelements are described below. References to where these
elements and subelements are addressed in DOE O 450.1 are also provided.

1.  DEFINITION OF AN EMS

The environmental management system (EMS) is a continuing cycle of
planning, implementing, evaluating, and improving processes and actions
undertaken to achieve environmental goals (DOE O 450.1 §1.).

The EMS is part of the Integrated Safety Management System (ISMS)
established pursuant to DOE P 450.4, *Safety Management System Policy*
(DOE O 450.1 §1.).

2.  Planning

The ISMS/EMS provides for the systematic planning of programs for public
health and environmental protection \[DOE O 450.1 §4.a.(1)(a)\].

The ISMS/EMS provides for the systematic planning of programs for
pollution prevention \[DOE O 450.1 §4.a.(1)(b)\].

### Environmental Aspects {#environmental-aspects .Sub3}

The ISMS/EMS includes policies \[and\] procedures to identify activities
with significant environmental impacts \[DOE O 450.1 §4.a.(2)\].

### Legal and Other Requirements {#legal-and-other-requirements .Sub3}

The ISMS/EMS provides for the systematic planning of programs for
compliance with applicable requirements \[DOE O 450.1 §4.a.(1)\].

The ISMS/EMS includes (if applicable) conformity of DOE proposed actions
with State Implementation Plans to attain and maintain national ambient
air quality standards \[DOE O 450.1 §4.b.(1)(a)\].

The ISMS/EMS includes (if applicable) implementation of a watershed
approach for surface water protection \[DOE O 450.1 §4.b.(1)(b)\].

The ISMS/EMS includes (if applicable) protection of other natural
resources, including biota \[DOE O 450.1 §4.b.(1)(d)\].

The ISMS/EMS includes (if applicable) protection of cultural resources
\[DOE O 450.1 §4.b.(1)(f)\].

The ISMS/EMS includes (if applicable) implementation of a site-wide
approach for groundwater protection \[DOE O 450.1 §4.b.(1)(c)\].

The ISMS/EMS includes (if applicable) protection of site resources from
wildland and operational fires \[DOE O 450.1 §4.b.(1)(e)\].

The ISMS/EMS provides for reduction or elimination of the generation of
waste, the release of pollutants to the environment, and the use of
Class I ozone-depleting substances (ODS) through source reduction,
reuse, segregation, and recycling and by procuring recycled-content
materials and environmentally preferable products and services \[DOE O
450.1 §4.b.(3)\].

The ISMS/EMS promotes the long-term stewardship of a site's natural and
cultural resources throughout its operational, closure, and postclosure
life cycle \[DOE O 450.1 §4.b.(2)\].

### Objectives and Targets {#objectives-and-targets .Sub3}

The ISMS/EMS includes measurable environmental goals, objectives, and
targets \[DOE O 450.1 §4.a.(3)\].

The ISMS/EMS includes site-specific goals that contribute to the
accomplishment of DOE pollution prevention and energy efficiency goals
\[DOE O 450.1 §5.c.(3)\].

Contractor ES&H performance objectives, performance measures, and
commitments include appropriate environmental elements based on the
environmental risks, impacts of activities at the site and established
Departmental pollution prevention/energy efficiency goals \[DOE O 450.1
§5.d.(17)\].

### Environmental Management Programs {#environmental-management-programs .Sub3}

The ISMS/EMS includes policies \[and\] procedures to manage, control,
and mitigate the potential impacts of site activities with significant
environmental impacts \[DOE O 450.1 §4.a.(2)\].

The ISMS/EMS includes (if applicable) conformity of DOE proposed actions
with State Implementation Plans to attain and maintain national ambient
air quality standards \[DOE O 450.1 §4.b.(1)(a)\].

The ISMS/EMS includes (if applicable) implementation of a watershed
approach for surface-water protection \[DOE O 450.1 §4.b.(1)(b)\].

The ISMS/EMS includes (if applicable) implementation of a site-wide
approach for groundwater protection \[DOE O 450.1 §4.b.(1)(c)\].

The ISMS/EMS includes (if applicable) protection of other natural
resources, including biota \[DOE O 450.1 §4.b.(1)(d)\].

The ISMS/EMS includes development and implementation of cost-effective
pollution prevention programs that use life-cycle assessment concepts
and practices in determining program return-on-investment \[DOE O 450.1
§5.c.(4)\].

The ISMS/EMS includes (if applicable) protection of cultural resources
\[DOE O 450.1 §4.b.(1)(f)\].

The ISMS/EMS includes (if applicable) implementation of a site-wide
approach for groundwater protection \[DOE O 450.1 §4.b.(1)(c)\].

The ISMS/EMS includes (if applicable) protection of site resources from
wildland and operational fires \[DOE O 450.1 §4.b.(1)(e)\].

The ISMS/EMS provides for reduction or elimination of: the generation of
waste, the release of pollutants to the environment, and the use of
Class I ozone-depleting substances (ODS), through source reduction,
reuse, segregation, and recycling and by procuring recycled-content
materials and environmentally preferable products and services \[DOE O
450.1 §4.b.(3)\].

The ISMS/EMS promotes the long-term stewardship of a site's natural and
cultural resources throughout its operational, closure, and postclosure
life cycle \[DOE O 450.1 §4.b.(2)\].

3.  Implementation and Operation

The ISMS/EMS provides for the integrated execution of programs for
public health and environmental protection, pollution prevention, and
compliance with applicable requirements \[DOE O 450.1 §4.a.(1)\].

### Structure and Responsibility {#structure-and-responsibility .Sub3}

\[Structure and responsibility is addressed in DOE P 450.4, *Safety
Management System Policy;* DOE P 411.1, *Safety Management Functions,
Responsibilities, and Authorities Policy;* DOE M 411.1-1C, *Safety
Management Functions, Responsibilities, and Authorities Manual;* and
other DOE policies, procedures, and requirements.\]

### Training, Awareness, and Competence {#training-awareness-and-competence .Sub3}

The ISMS/EMS includes training to identify activities with significant
environmental impacts \[DOE O 450.1 §4.a.(2)\].

The ISMS/EMS includes training to manage, control, and mitigate the
potential impacts of site activities with significant environmental
impacts \[DOE O 450.1 §4.a.(2)\].

The ISMS/EMS includes training to assess performance and implement
corrective actions where needed \[DOE O 450.1 §4.a.(2)\].

### Communication {#communication .Sub3}

The ISMS/EMS provides for obtaining, as appropriate, community advice
relevant to aspects of "Greening the Government" Executive Orders
through new or existing outreach programs \[DOE O 450.1 §5.d.(3)\].

### Environmental Management System Documentation {#environmental-management-system-documentation .Sub3}

Approved ISMS descriptions have been updated, as necessary, to include
EMS requirements \[DOE O 450.1 §.5.d.(2)\].

### Document Control {#document-control .Sub3}

Document control is addressed in other DOE policies, procedures, and
requirements.

### Operational Control {#operational-control .Sub3}

The ISMS/EMS includes procedures to manage, control, and mitigate the
potential impacts of site activities with significant environmental
impacts \[DOE O 450.1 §4.a.(2)\].

### Emergency Preparedness and Response {#emergency-preparedness-and-response .Sub3}

Emergency preparedness and response is addressed in other DOE policies,
procedures and requirements.

4.  Checking and Corrective Action

The ISMS/EMS provides for the evaluation of programs for compliance with
applicable requirements \[DOE O 450.1 §4.a.(1)(c)\].

The ISMS/EMS provides for the evaluation of programs for public health
and environmental protection \[DOE O 450.1 §4.a.(1)(a)\].

The ISMS/EMS provides for the evaluation of programs for pollution
prevention \[DOE O 450.1 §4.a.(1)(b)\].

ISMS/EMS implementation is assessed as a component of the implementation
of DOE P 450.5, *Line Environment, Safety and Health Oversight* (DOE O
450.1 §5.b.).

### Monitoring and Measurement {#monitoring-and-measurement .Sub3}

The ISMS/EMS includes policies and procedures to assess performance
\[DOE O 450.1 §4.a.(2)\].

Contractor ES&H self-assessment programs within the framework of DOE P
450.5 are established and continue to be effective \[DOE O 450.1
§5.d.(16)\].

The ISMS/EMS ensures the early identification of, and appropriate
response to, potential adverse environmental impacts associated with DOE
operations, including, as appropriate, preoperational characterization
and assessment and effluent and surveillance monitoring \[DOE O 450.1
§4.b.(4)\].

The ISMS/EMS provides for the conduct of environmental monitoring, as
appropriate, to support the site's ISMS to detect, characterize, and
respond to releases from DOE activities \[DOE O 450.1 §5.d.(14)\].

The ISMS/EMS provides for the conduct of environmental monitoring, as
appropriate, to assess impacts \[DOE O 450.1 §5.d.(14)\].

The ISMS/EMS provides for the conduct of environmental monitoring, as
appropriate, to estimate dispersal patterns in the environment \[DOE O
450.1 §5.d.(14)\].

The ISMS/EMS provides for the conduct of environmental monitoring, as
appropriate, to characterize the pathways of exposure to members of the
public; and to characterize the exposures and doses to individuals, and
to the population \[DOE O 450.1 §5.d.(14)\].

The ISMS/EMS provides for the conduct of environmental monitoring, as
appropriate, to evaluate the potential impacts to the biota in the
vicinity of the DOE activity \[DOE O 450.1 §5.d.(14)\].

The ISMS/EMS provides for the implementation of the analytical work
supporting environmental monitoring using a consistent system for
collecting, assessing, and documenting environmental data of known and
documented quality \[DOE O 450.1 §5.d.(15)(a)\].

The ISMS/EMS provides for the implementation of the analytical work
supporting environmental monitoring using a validated and consistent
approach for sampling and analysis of radionuclide samples to ensure
laboratory data meet program-specific needs and requirements within the
framework of a performance-based approach for analytical laboratory work
\[DOE O 450.1 §5.d.(15)(b)\].

The ISMS/EMS provides for the implementation of the analytical work
supporting environmental monitoring using an integrated sampling
approach to avoid duplicative data collection \[DOE O 450.1
§5.d.(15)(c)\].

### Nonconformance and Corrective and Preventive Action {#nonconformance-and-corrective-and-preventive-action .Sub3}

The ISMS/EMS includes policies \[and\] procedures to implement
corrective actions where needed \[DOE O 450.1 §4.a.(2)\].

### Records {#records .Sub3}

Records are not specifically addressed in DOE O 450.1. Records
management is addressed in other DOE policies, procedures, and
requirements.

### Environmental Management System Assessment {#environmental-management-system-assessment .Sub3}

The ISMS/EMS provides for the evaluation of programs for public health
and environmental protection, pollution prevention, and compliance with
applicable requirements \[DOE O 450.1 §4.a.(1)\].

Contractor ES&H self-assessment programs within the framework of DOE P
450.5 are established and continue to be effective \[DOE O 450.1
§5.d.(16)\].

5.  Management Review

The ISMS/EMS provides for the evaluation of programs for public health
and environmental protection, pollution prevention, and compliance with
applicable requirements \[DOE O 450.1 §4.a.(1)\].

The ISMS/EMS includes policies \[and\] procedures to assess performance
\[DOE O 450.1 §4.a.(2)\].

The ISMS/EMS reviews annually, and updates (when appropriate) the site's
measurable environmental goals, objectives, and targets \[DOE O 450.1
§4.a.(3)\].

ISMS/EMS implementation is assessed as a component of the implementation
of DOE P 450.5, *Line Environment, Safety and Health Oversight* (DOE O
450.1 §5.b.).

Contractor ES&H performance objectives, performance measures, and
commitments are reviewed through the annual ISM review process
\[established pursuant to DEAR 970.5223-1 (e)\] \[DOE O 450.1
§5.d.(17)\].

1.  EMS Roadmap Templates

    1.  Creating an EMS Roadmap

It may be useful for sites to develop a document that lists all the EMS
elements required by DOE O 450.1 and describes their location in the
ISMS description. This document can act as a checklist of EMS
requirements and would allow an assessment team or other interested
party to quickly determine where all EMS elements are located or
referenced in the ISMS description.

Table 1 is an example of an EMS roadmap. It depicts the EMS elements
required by DOE O 450.1 in column A. In some cases, the DOE O 450.1
requirements are very specific and should therefore be addressed with
appropriate detail in the ISMS description. The DOE site should place
the ISMS description chapter or section in the column B field and then
describe the location of EMS elements documentation in the column C
field. A full roadmap template is provided in section B.2.2.

Table 1. EMS Roadmap Example

+-------------------------------+---------------+---------------------+
| **A. EMS Element**            | **B. Location | **C. Document       |
|                               | in ISMS       | Location**          |
|                               | Description** |                     |
|                               |               | **(where a document |
|                               |               | exists)**           |
+-------------------------------+---------------+---------------------+
| **1----PLANNING**             |               |                     |
+-------------------------------+---------------+---------------------+
|                               |               |                     |
+-------------------------------+---------------+---------------------+
| **DOE O 450.1                 | Chapter 1,    | [www.EMS Program    |
| Element----**The ISMS/EMS     | Section 1.3,  | for]()              |
| provides for the systematic   | 1.2           | [Environment.DOEsi  |
| planning of programs for      |               | te.gov]{.underline} |
| pollution prevention \[DOE O  |               |                     |
| 450.1 §4.a.(1)(b)\].          |               |                     |
+-------------------------------+---------------+---------------------+
| 1.1---- ENVIRONMENTAL ASPECTS |               |                     |
+-------------------------------+---------------+---------------------+
|                               |               |                     |
+-------------------------------+---------------+---------------------+
| **DOE O 450.1                 | Chapter 3,    | Room 2002, ISMS/EMS |
| Element----**The ISMS/EMS     | Section 1.1,  | file Cabinet        |
| includes policies \[and\]     | 1.2, 1.3      |                     |
| procedures to identify        |               |                     |
| activities with significant   |               |                     |
| environmental impacts \[DOE O |               |                     |
| 450.1 §4.a.(2)\].             |               |                     |
+-------------------------------+---------------+---------------------+
|                               |               |                     |
+-------------------------------+---------------+---------------------+
| **1.2----LEGAL AND OTHER      |               |                     |
| REQUIREMENTS**                |               |                     |
+-------------------------------+---------------+---------------------+

2.  EMS Roadmap Template

The EMS Roadmap Template (Task 8) is not a requirement of DOE O 450.1;
however, the site may opt to use this template (see Table 2) as a tool
to document its full integration of the EMS elements set forth in DOE O
450.1 into its ISMS.

Table 2. EMS roadmap template

+-----------------------------------------+-----------+----------------+
| **EMS Element**                         | *         | **Document     |
|                                         | *Location | Location\      |
|                                         | in ISMS   | (where a       |
|                                         | Desc      | document       |
|                                         | ription** | exists)**      |
+=========================================+===========+================+
| **1----PLANNING**                       |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS provides for the systematic    |           |                |
| planning of programs for public health  |           |                |
| and environmental protection \[DOE O    |           |                |
| 450.1 §4.a.(1)(a)\].                    |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS provides for the systematic    |           |                |
| planning of programs for pollution      |           |                |
| prevention \[DOE O 450.1 §4.a.(1)(b)\]. |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| 1.1---- ENVIRONMENTAL ASPECTS           |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes policies \[and\]      |           |                |
| procedures to identify activities with  |           |                |
| significant environmental impacts \[DOE |           |                |
| O 450.1 §4.a.(2)\].                     |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **1.2----LEGAL AND OTHER REQUIREMENTS** |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS provides for the systematic    |           |                |
| planning of programs for compliance     |           |                |
| with applicable requirements \[DOE O    |           |                |
| 450.1 §4.a.(1)\].                       |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| conformity of DOE proposed actions with |           |                |
| State Implementation Plans to attain    |           |                |
| and maintain national ambient air       |           |                |
| quality standards \[DOE O 450.1         |           |                |
| §4.b.(1)(a)\].                          |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| implementation of a watershed approach  |           |                |
| for surface water protection \[DOE O    |           |                |
| 450.1 §4.b.(1)(b)\].                    |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| protection of other natural resources,  |           |                |
| including biota \[DOE O 450.1           |           |                |
| §4.b.(1)(d)\].                          |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| protection of cultural resources \[DOE  |           |                |
| O 450.1 §4.b.(1)(f)\].                  |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| implementation of a site-wide approach  |           |                |
| for groundwater protection \[DOE O      |           |                |
| 450.1 §4.b.(1)(c)\].                    |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| protection of site resources from       |           |                |
| wildland and operational fires\[DOE     |           |                |
| O 450.1 §4.b.(1)(e)\].                  |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS provides for reduction or      |           |                |
| elimination of: the generation of       |           |                |
| waste, the release of pollutants to the |           |                |
| environment, and the use of Class I     |           |                |
| ozone-depleting substances (ODS),       |           |                |
| through source reduction, reuse,        |           |                |
| segregation, and recycling and by       |           |                |
| procuring recycled-content materials    |           |                |
| and environmentally preferable products |           |                |
| and services \[DOE O 450.1 §4.b.(3)\].  |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS promotes the long-term         |           |                |
| stewardship of a site's natural and     |           |                |
| cultural resources throughout its       |           |                |
| operational, closure, and postclosure   |           |                |
| life cycle \[DOE O 450.1 §4.b.(2)\].    |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **1.3----OBJECTIVES AND TARGETS**       |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes measurable            |           |                |
| environmental goals, objectives, and    |           |                |
| targets \[DOE O 450.1 §4.a.(3)\].       |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes site-specific goals   |           |                |
| that contribute to the accomplishment   |           |                |
| of DOE pollution prevention and energy  |           |                |
| efficiency goals \[DOE O 450.1          |           |                |
| §5.c.(3)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS                       |           |                |
| Element----**Contractor ES&H            |           |                |
| performance objectives, performance     |           |                |
| measures, and commitments include       |           |                |
| appropriate environmental elements      |           |                |
| based on the environmental risks,       |           |                |
| impacts of activities at the site and   |           |                |
| established Departmental pollution      |           |                |
| prevention/energy efficiency goals      |           |                |
| \[DOE O 450.1 §5.d.(17)\].              |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **1.4----ENVIRONMENTAL MANAGEMENT       |           |                |
| PROGRAMS (EMPS)**                       |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes policies \[and\]      |           |                |
| procedures to manage, control, and      |           |                |
| mitigate the potential impacts of site  |           |                |
| activities with significant             |           |                |
| environmental impacts \[DOE O 450.1     |           |                |
| §4.a.(2)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| conformity of DOE proposed actions with |           |                |
| State Implementation Plans to attain    |           |                |
| and maintain national ambient air       |           |                |
| quality standards \[DOE O 450.1         |           |                |
| §4.b.(1)(a)\].                          |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| implementation of a watershed approach  |           |                |
| for surface water protection \[DOE O    |           |                |
| 450.1 §4.b.(1)(b)\].                    |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| implementation of a site-wide approach  |           |                |
| for groundwater protection \[DOE O      |           |                |
| 450.1 §4.b.(1)(c)\].                    |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| protection of other natural resources,  |           |                |
| including biota \[DOE O 450.1           |           |                |
| §4.b.(1)(d)\].                          |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes development and       |           |                |
| implementation of cost-effective        |           |                |
| pollution prevention programs that use  |           |                |
| life-cycle assessment concepts and      |           |                |
| practices in determining program        |           |                |
| return-on-investment \[DOE O 450.1      |           |                |
| §5.c.(4)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| protection of cultural resources \[DOE  |           |                |
| O 450.1 §4.b.(1)(f)\].                  |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes (if applicable)       |           |                |
| protection of site resources from       |           |                |
| wildland and operational fires \[DOE    |           |                |
| O 450.1 §4.b.(1)(e)\].                  |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS provides for reduction or      |           |                |
| elimination of: the generation of       |           |                |
| waste, the release of pollutants to the |           |                |
| environment, and the use of Class I     |           |                |
| ozone-depleting substances (ODS),       |           |                |
| through source reduction, reuse,        |           |                |
| segregation, and recycling and by       |           |                |
| procuring recycled-content materials    |           |                |
| and environmentally preferable products |           |                |
| and services \[DOE O 450.1 §4.b.(3)\].  |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS promotes the long-term         |           |                |
| stewardship of a site's natural and     |           |                |
| cultural resources throughout its       |           |                |
| operational, closure, and postclosure   |           |                |
| life cycle \[DOE O 450.1 §4.b.(2)\].    |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2----IMPLEMENTATION AND OPERATION**   |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS provides for the integrated    |           |                |
| execution of programs for public health |           |                |
| and environmental protection, pollution |           |                |
| prevention, and compliance with         |           |                |
| applicable requirements \[DOE O 450.1   |           |                |
| §4.a.(1)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| ##  {#section-5 .sub-heading}           | ##        | #              |
|                                         |   {#secti | #  {#section-7 |
|                                         | on-6 .sub |  .sub-heading} |
|                                         | -heading} |                |
+-----------------------------------------+-----------+----------------+
| **2.1----ROLES, AUTHORITIES AND         |           |                |
| RESPONSIBILITIES**                      |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| Structure and responsibility is         |           |                |
| addressed in DOE P 450.4, *Safety       |           |                |
| Management System Policy*; DOE P 411.1, |           |                |
| *Safety Management Functions            |           |                |
| Responsibilities and Authorities        |           |                |
| Policy*; DOE M 411.1B, *Safety          |           |                |
| Management* *Functions,                 |           |                |
| Responsibilities and Authorities*; and  |           |                |
| other DOE policies, procedures and      |           |                |
| requirements.                           |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.2---- TRAINING, AWARENESS, AND      |           |                |
| COMPETENCE**                            |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes training to identify  |           |                |
| activities with significant             |           |                |
| environmental impacts \[DOE O 450.1     |           |                |
| §4.a.(2)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes training to manage,   |           |                |
| control, and mitigate the potential     |           |                |
| impacts of site activities with         |           |                |
| significant environmental impacts \[DOE |           |                |
| O 450.1 §4.a.(2)\].                     |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS includes training to assess    |           |                |
| performance and implement corrective    |           |                |
| actions where needed (DOE O 450.1       |           |                |
| §4.a.(2).                               |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.3----COMMUNICATION**                |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**The      |           |                |
| ISMS/EMS provides for obtaining, as     |           |                |
| appropriate, community advice relevant  |           |                |
| to aspects of "Greening the Government" |           |                |
| Executive orders, through new or        |           |                |
| existing outreach programs \[DOE O      |           |                |
| 450.1 §5.d.(3)\].                       |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.4----EMS DOCUMENTATION**            |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**Approved |           |                |
| ISMS descriptions have been updated, as |           |                |
| necessary, to include EMS requirements  |           |                |
| \[DOE O 450.1 §.5.d.(2)\].              |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.5---- DOCUMENT CONTROL**            |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| Document control is addressed in other  |           |                |
| DOE policies                            |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| 2.6---- OPERATIONAL CONTROL             |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS includes procedures to manage, |           |                |
| control, and mitigate the potential     |           |                |
| impacts of site activities with         |           |                |
| significant environmental impacts \[DOE |           |                |
| O 450.1 §4.a.(2)\].                     |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.7---- EMERGENCY PREPAREDNESS AND    |           |                |
| RESPONSE**                              |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| Emergency preparedness and response is  |           |                |
| addressed in other DOE policies,        |           |                |
| procedures and requirements.            |           |                |
+-----------------------------------------+-----------+----------------+
| ##  {#section-8 .sub-heading}           | ##        | ##             |
|                                         |   {#secti |   {#section-10 |
|                                         | on-9 .sub |  .sub-heading} |
|                                         | -heading} |                |
+-----------------------------------------+-----------+----------------+
| **2.8----CHECKING AND CORRECTIVE        |           |                |
| ACTION**                                |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the evaluation of |           |                |
| programs for compliance with applicable |           |                |
| requirements \[DOE O 450.1              |           |                |
| §4.a.(1)(c)\].                          |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the evaluation of |           |                |
| programs for public health and          |           |                |
| environmental protection \[DOE O 450.1  |           |                |
| §4.a.(1)(a)\].                          |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the evaluation of |           |                |
| programs for pollution prevention \[DOE |           |                |
| O 450.1 §4.a.(1)(b)\].                  |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| ISMS/EMS implementation is assessed as  |           |                |
| a component of the implementation of    |           |                |
| DOE P 450.5, *Line Environment, Safety  |           |                |
| and Health Oversight* (DOE O 450.1      |           |                |
| §5.b.)                                  |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.9----MONITORING AND MEASUREMENT**   |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS includes policies \[and\]      |           |                |
| procedures to assess performance \[DOE  |           |                |
| O 450.1 §4.a.(2)\].                     |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| Contractor ES&H self-assessment         |           |                |
| programs within the framework of DOE P  |           |                |
| 450.5 are established and continue to   |           |                |
| be effective \[DOE O 450.1 §5.d.(16)\]. |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS ensures the early              |           |                |
| identification of, and appropriate      |           |                |
| response to, potential adverse          |           |                |
| environmental impacts associated with   |           |                |
| DOE operations, including, as           |           |                |
| appropriate, preoperational             |           |                |
| characterization and assessment and     |           |                |
| effluent and surveillance monitoring    |           |                |
| \[DOE O 450.1 §4.b.(4)\].               |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the conduct of    |           |                |
| environmental monitoring, as            |           |                |
| appropriate, to support the site's      |           |                |
| ISMS, to detect, characterize, and      |           |                |
| respond to releases from DOE activities |           |                |
| \[DOE O 450.1 §5.d.(14)\].              |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the conduct of    |           |                |
| environmental monitoring, as            |           |                |
| appropriate, to assess impacts \[DOE O  |           |                |
| 450.1 §5.d.(14)\].                      |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the conduct of    |           |                |
| environmental monitoring, as            |           |                |
| appropriate, to estimate dispersal      |           |                |
| patterns in the environment \[DOE O     |           |                |
| 450.1 §5.d.(14)\].                      |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the conduct of    |           |                |
| environmental monitoring, as            |           |                |
| appropriate, to characterize the        |           |                |
| pathways of exposure to members of the  |           |                |
| public; and to characterize the         |           |                |
| exposures and doses to individuals, and |           |                |
| to the population \[DOE O 450.1         |           |                |
| §5.d.(14)\].                            |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the conduct of    |           |                |
| environmental monitoring, as            |           |                |
| appropriate, to evaluate the potential  |           |                |
| impacts to the biota in the vicinity of |           |                |
| the DOE activity \[DOE O 450.1          |           |                |
| §5.d.(14)\].                            |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the               |           |                |
| implementation of the analytical work   |           |                |
| supporting environmental monitoring     |           |                |
| using a consistent system for           |           |                |
| collecting, assessing, and documenting  |           |                |
| environmental data of known and         |           |                |
| documented quality \[DOE O 450.1        |           |                |
| §5.d.(15)(a)\].                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the               |           |                |
| implementation of the analytical work   |           |                |
| supporting environmental monitoring     |           |                |
| using a validated and consistent        |           |                |
| approach for sampling and analysis of   |           |                |
| radionuclide samples to ensure          |           |                |
| laboratory data meet program-specific   |           |                |
| needs and requirements within the       |           |                |
| framework of a performance-based        |           |                |
| approach for analytical laboratory work |           |                |
| \[DOE O 450.1 §5.d.(15)(b)\].           |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the               |           |                |
| implementation of the analytical work   |           |                |
| supporting environmental monitoring     |           |                |
| using an integrated sampling approach   |           |                |
| to avoid duplicative data collection    |           |                |
| \[DOE O 450.1 §5.d.(15)(c)\].           |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.10----NONCONFORMANCE AND CORRECTIVE |           |                |
| AND PREVENTIVE ACTION**                 |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS includes policies, procedures  |           |                |
| to implement corrective actions where   |           |                |
| needed \[DOE O 450.1 §4.a.(2)\].        |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **2.11----RECORDS**                     |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**This is  |           |                |
| addressed in other DOE policies,        |           |                |
| procedures and requirements.            |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **3----INTERNAL ASSESSMENTS.**          |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the evaluation of |           |                |
| programs for public health and          |           |                |
| environmental protection, pollution     |           |                |
| prevention, and compliance with         |           |                |
| applicable requirements \[DOE O 450.1   |           |                |
| §4.a.(1)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| Contractor ES&H self-assessment         |           |                |
| programs within the framework of DOE P  |           |                |
| 450.5 are established and continue to   |           |                |
| be effective \[DOE O 450.1 §5.d.(16)\]. |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **4----MANAGEMENT REVIEW.**             |           |                |
+-----------------------------------------+-----------+----------------+
|                                         |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS provides for the evaluation of |           |                |
| programs for public health and          |           |                |
| environmental protection, pollution     |           |                |
| prevention, and compliance with         |           |                |
| applicable requirements \[DOE O 450.1   |           |                |
| §4.a.(1)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS includes policies, procedures  |           |                |
| to assess performance \[DOE O 450.1     |           |                |
| §4.a.(2)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----** The     |           |                |
| ISMS/EMS reviews annually, and updates  |           |                |
| (when appropriate) the site's           |           |                |
| measurable environmental goals,         |           |                |
| objectives, and targets \[DOE O 450.1   |           |                |
| §4.a.(3)\].                             |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| ISMS/EMS implementation is assessed as  |           |                |
| a component of the implementation of    |           |                |
| DOE P 450.5*, Line Environment, Safety  |           |                |
| and Health Oversight* (DOE O 450.1      |           |                |
| §5.b.).                                 |           |                |
+-----------------------------------------+-----------+----------------+
| **DOE O 450.1 EMS Element----**         |           |                |
| Contractor ES&H performance objectives, |           |                |
| performance measures, and commitments   |           |                |
| are reviewed through the annual ISM     |           |                |
| review process \[established pursuant   |           |                |
| to DEAR 970.5223-1 (e)\] \[DOE O 450.1  |           |                |
| §5.d.(17).                              |           |                |
+-----------------------------------------+-----------+----------------+

2.  Environmental Management Programs Template

    1.  Documenting Environmental Management Programs

The example below (Table 3) illustrates how the Environmental Management
Program (EMP) template can be used. Table 3 shows an environmental
management program template developed by a DOE site that has been a
useful guide for dozens of organizations implementing EMSs. The template
simply ties relevant EMS Elements together in a single place and can be
used as a guide or checklist to ensure all necessary information is
contained in existing or new programs. Instructions explaining how the
template was completed follow the example in Table 3. Tables 4, 5, and 6
of this appendix contain additional examples that illustrate how fields
6, 10, and 13 can be completed.

**[Table 3. Example of completed Environmental Management Program
Template]{.underline}**

+----------------------------+-----+----+-----------------------------+
| ENVIRONMENTAL MANAGEMENT   |     |    |                             |
| PROGRAM - WASTE MANAGEMENT |     |    |                             |
| DIVISION                   |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **A. Significant Aspect:** | *   |    | WMP Volume one              |
|                            | *B. |    |                             |
| Regulated Industrial Waste | D   |    |                             |
|                            | ocu |    |                             |
|                            | men |    |                             |
|                            | t** |    |                             |
|                            |     |    |                             |
|                            | **C |    |                             |
|                            | ont |    |                             |
|                            | rol |    |                             |
|                            | C   |    |                             |
|                            | ode |    |                             |
|                            | :** |    |                             |
+----------------------------+-----+----+-----------------------------+
|                            | *   |    | 1                           |
|                            | *C. |    |                             |
|                            | R   |    |                             |
|                            | evi |    |                             |
|                            | sio |    |                             |
|                            | n** |    |                             |
+----------------------------+-----+----+-----------------------------+
| **1. Objective Number 1:** |     |    |                             |
|                            |     |    |                             |
| Maintain compliance with   |     |    |                             |
| all applicable operational |     |    |                             |
| and reporting requirements |     |    |                             |
| associated with waste      |     |    |                             |
| pickup and storage, waste  |     |    |                             |
| treatment, offsite         |     |    |                             |
| transportation of waste,   |     |    |                             |
| and maintenance            |     |    |                             |
| activities.                |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **2. Targets:**            |     |    |                             |
|                            |     |    |                             |
| Target 1 -- Maintain 100%  |     |    |                             |
| on time regulatory         |     |    |                             |
| required reporting for     |     |    |                             |
| five key regulatory        |     |    |                             |
| reports **(see \# 6        |     |    |                             |
| Performance indicators     |     |    |                             |
| below).**                  |     |    |                             |
|                            |     |    |                             |
| Target 2 -- Conduct        |     |    |                             |
| maintenance operations in  |     |    |                             |
| accordance with all        |     |    |                             |
| applicable operational and |     |    |                             |
| reporting requirements.    |     |    |                             |
|                            |     |    |                             |
| Target 3 -- Work with the  |     |    |                             |
| Environmental Services     |     |    |                             |
| Division to resolve EPA    |     |    |                             |
| Phase II recommendations.  |     |    |                             |
| *(See EPA report No. XXXX, |     |    |                             |
| located at Records Storage |     |    |                             |
| Room 4002 of the Waste     |     |    |                             |
| Management Division)*      |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **3. Reason for            |     |    |                             |
| Significance:**            |     |    |                             |
|                            |     |    |                             |
| Since Waste Management     |     |    |                             |
| Division operates in a     |     |    |                             |
| heavily regulated and      |     |    |                             |
| structured operations      |     |    |                             |
| envelope, it was           |     |    |                             |
| determined that, due to    |     |    |                             |
| compliance requirements,   |     |    |                             |
| all Waste Management       |     |    |                             |
| Division operational       |     |    |                             |
| aspects would be           |     |    |                             |
| considered significant.    |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **4. Potential             |     |    |                             |
| En                         |     |    |                             |
| vironmental/Organizational |     |    |                             |
| Impacts:**                 |     |    |                             |
|                            |     |    |                             |
| Specific operational       |     |    |                             |
| controls for standard      |     |    |                             |
| Waste Management Division  |     |    |                             |
| operations are listed in   |     |    |                             |
| the governing Standard     |     |    |                             |
| Operating Procedures       |     |    |                             |
| (SOPs) these controls      |     |    |                             |
| provide descriptions of    |     |    |                             |
| Potential                  |     |    |                             |
| En                         |     |    |                             |
| vironmental/Organizational |     |    |                             |
| Impacts.                   |     |    |                             |
|                            |     |    |                             |
| **Location:**              |     |    |                             |
| [http://Waste Management   |     |    |                             |
| Division-SOP-Potenti       |     |    |                             |
| al-Impacts-at-FacilityX]() |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **5. Legal and Other       |     |    |                             |
| Requirements (Specify):**  |     |    |                             |
|                            |     |    |                             |
| Applicable DOE Orders,     |     |    |                             |
| RCRA Permits limits,       |     |    |                             |
| Facility Safety Limits,    |     |    |                             |
| and state and county       |     |    |                             |
| requirements. References   |     |    |                             |
| to these requirements are  |     |    |                             |
| found in applicable SOPs,  |     |    |                             |
| Plans, Reports, and        |     |    |                             |
| Administrative Procedures, |     |    |                             |
| located in Waste           |     |    |                             |
| Management Divisions       |     |    |                             |
| ISMS/EMS Description       |     |    |                             |
| located at:                |     |    |                             |
|                            |     |    |                             |
| **Location:**              |     |    |                             |
| (<http                     |     |    |                             |
| ://Waste-Management-Divisi |     |    |                             |
| ons-ISMS/EMS-description>) |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **6. Performance           |     |    |                             |
| Indicators:** *(for        |     |    |                             |
| additional examples see    |     |    |                             |
| Table 4)*                  |     |    |                             |
|                            |     |    |                             |
| A. Track on-time reporting |     |    |                             |
| for the 5 key regulatory   |     |    |                             |
| reports identified.        |     |    |                             |
|                            |     |    |                             |
| \(1\) (State) Department   |     |    |                             |
| of Environmental           |     |    |                             |
| Conservation Hazardous     |     |    |                             |
| Waste Reduction Plan       |     |    |                             |
|                            |     |    |                             |
| \(2\) (State) Department   |     |    |                             |
| of Environmental           |     |    |                             |
| Conservation Update to     |     |    |                             |
| site's FFCA Site Treatment |     |    |                             |
| Plan                       |     |    |                             |
|                            |     |    |                             |
| \(3\) (State) Department   |     |    |                             |
| of Environmental           |     |    |                             |
| Conservation Annual Waste  |     |    |                             |
| Generator Report           |     |    |                             |
|                            |     |    |                             |
| \(4\) (Agency) Department  |     |    |                             |
| of Energy Annual and       |     |    |                             |
| Quarterly Pollution        |     |    |                             |
| Prevention and Waste       |     |    |                             |
| Generator Reports          |     |    |                             |
|                            |     |    |                             |
| \(5\) (Site) DOE Quarterly |     |    |                             |
| Waste Forecasts            |     |    |                             |
|                            |     |    |                             |
| B. Track indicators in the |     |    |                             |
| Waste Management Division  |     |    |                             |
| Database **(Location:**    |     |    |                             |
| Computer in the Records    |     |    |                             |
| Storage Room 4002 of the   |     |    |                             |
| Waste Management Division) |     |    |                             |
|                            |     |    |                             |
| C. Maintain evidence that  |     |    |                             |
| demonstrates progress      |     |    |                             |
| toward resolving EPA Phase |     |    |                             |
| II recommendations **(See  |     |    |                             |
| \# 2 Target above).**      |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **7. Environmental         |     |    |                             |
| Management Program         |     |    |                             |
| Description:**             |     |    |                             |
|                            |     |    |                             |
| Compliance with regulatory |     |    |                             |
| reporting is mandated by   |     |    |                             |
| RCRA requirements as well  |     |    |                             |
| as DOE, State, and local   |     |    |                             |
| regulations. The           |     |    |                             |
| compilation and            |     |    |                             |
| distribution of annual     |     |    |                             |
| reports are tracked by     |     |    |                             |
| Waste Management Division  |     |    |                             |
| personnel as departmental  |     |    |                             |
| milestones.                |     |    |                             |
|                            |     |    |                             |
| **Location:**              |     |    |                             |
| [http://Waste Management   |     |    |                             |
| Division-annual-reports]() |     |    |                             |
|                            |     |    |                             |
| The [Waste Management      |     |    |                             |
| Division Maintenance       |     |    |                             |
| Implementation             |     |    |                             |
| Plan]{.underline},         |     |    |                             |
| WMP-222, sets requirements |     |    |                             |
| for all                    |     |    |                             |
| maintenance-related        |     |    |                             |
| activities. These plans    |     |    |                             |
| provide detailed           |     |    |                             |
| descriptions of the        |     |    |                             |
| activities, tasks, and     |     |    |                             |
| requirements to maintain   |     |    |                             |
| compliance with            |     |    |                             |
| operational requirement of |     |    |                             |
| the ISMS/EMS program.      |     |    |                             |
|                            |     |    |                             |
| **Location:**              |     |    |                             |
| [http://Waste Management   |     |    |                             |
| Division-Maintena          |     |    |                             |
| nce-Implementation-Plan]() |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **8. Operational           |     |    |                             |
| Controls:**                |     |    |                             |
|                            |     |    |                             |
| Specific operational       |     |    |                             |
| controls for standard      |     |    |                             |
| Waste Management Division  |     |    |                             |
| operations are listed in   |     |    |                             |
| their governing SOPs. For  |     |    |                             |
| nonroutine activities,     |     |    |                             |
| Technical Work Documents,  |     |    |                             |
| Work Permits, radiation    |     |    |                             |
| Work Permits, and/or       |     |    |                             |
| Timely Orders list         |     |    |                             |
| job-specific operational   |     |    |                             |
| controls.                  |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **9. Budget (resources):** |     |    |                             |
|                            |     |    |                             |
| Describe the budget        |     |    |                             |
| resources that enable this |     |    |                             |
| management program and/or  |     |    |                             |
| provide a reference to the |     |    |                             |
| document that describes    |     |    |                             |
| this allotment.            |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **10. Structure,           |     |    |                             |
| Authorities,               |     |    |                             |
| Responsibilities:** *(for  |     |    |                             |
| additional examples see    |     |    |                             |
| Table 5)*                  |     |    |                             |
|                            |     |    |                             |
| Employee qualifications    |     |    |                             |
| are in individual Roles,   |     |    |                             |
| Responsibilities,          |     |    |                             |
| Accountabilities and       |     |    |                             |
| Authorities (R2A2's)       |     |    |                             |
| documents.                 |     |    |                             |
| Responsibilities for all   |     |    |                             |
| personnel associated with  |     |    |                             |
| this objective are         |     |    |                             |
| delineated in the          |     |    |                             |
| applicable procedures and  |     |    |                             |
| are explicitly described   |     |    |                             |
| in the ISMS/EMS            |     |    |                             |
| description.               |     |    |                             |
|                            |     |    |                             |
| **Location:**              |     |    |                             |
| (<http                     |     |    |                             |
| ://Waste-Management-Divisi |     |    |                             |
| ons-ISMS/EMS-description>) |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **11. Records:**           |     |    |                             |
|                            |     |    |                             |
| All Waste Management       |     |    |                             |
| Division records are       |     |    |                             |
| maintained in accordance   |     |    |                             |
| with applicable site       |     |    |                             |
| policies and procedures    |     |    |                             |
| for records management,    |     |    |                             |
| including Waste Management |     |    |                             |
| Division-ADM-333, Records  |     |    |                             |
| Storage and Retrieval      |     |    |                             |
| System.                    |     |    |                             |
|                            |     |    |                             |
| **Location:** Hard copy of |     |    |                             |
| records can be found in    |     |    |                             |
| the Records Storage Room   |     |    |                             |
| 4002 of the Waste          |     |    |                             |
| Management Division        |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **12. Documents:**         |     |    |                             |
|                            |     |    |                             |
| All Waste Management       |     |    |                             |
| Division documents are     |     |    |                             |
| controlled and distributed |     |    |                             |
| in accordance with the     |     |    |                             |
| [Waste Management Division |     |    |                             |
| Procedure on Control and   |     |    |                             |
| Distribution of Controlled |     |    |                             |
| Documents]{.underline}     |     |    |                             |
| Waste Management Division  |     |    |                             |
| -ADM-330, and [Records,    |     |    |                             |
| Storage & Retrieval        |     |    |                             |
| System]{.underline} Waste  |     |    |                             |
| Management Division        |     |    |                             |
| -ADM-333.                  |     |    |                             |
|                            |     |    |                             |
| A complete list of         |     |    |                             |
| documents including, the   |     |    |                             |
| following.                 |     |    |                             |
|                            |     |    |                             |
| The environmental          |     |    |                             |
| management program         |     |    |                             |
| description (also          |     |    |                             |
| referenced in \# 7,        |     |    |                             |
| Environmental Management   |     |    |                             |
| Program Description        |     |    |                             |
| above).                    |     |    |                             |
|                            |     |    |                             |
| The Waste Management       |     |    |                             |
| Division material          |     |    |                             |
| substitution plan.         |     |    |                             |
|                            |     |    |                             |
| Documents relating to      |     |    |                             |
| operational and reporting  |     |    |                             |
| requirements for waste     |     |    |                             |
| pickup and storage, waste  |     |    |                             |
| treatment, offsite         |     |    |                             |
| transportation of          |     |    |                             |
| disposal, or maintenance   |     |    |                             |
| activities, can be found   |     |    |                             |
| at: **Location:**          |     |    |                             |
| (<http                     |     |    |                             |
| ://Waste-Management-Divisi |     |    |                             |
| ons-ISMS/EMS-description>) |     |    |                             |
| \[in most cases it is more |     |    |                             |
| convenient to provide a    |     |    |                             |
| reference to documents     |     |    |                             |
| rather than list all of    |     |    |                             |
| them in this field\]       |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **13. Training:** *(for    |     |    |                             |
| additional examples se     |     |    |                             |
| Table 6)*                  |     |    |                             |
|                            |     |    |                             |
| Required training for all  |     |    |                             |
| Waste Management Division  |     |    |                             |
| staff members is           |     |    |                             |
| delineated in documented   |     |    |                             |
| Job Training Assessments   |     |    |                             |
| (JTAs), which are kept on  |     |    |                             |
| file by the site Central   |     |    |                             |
| Training Office. The Waste |     |    |                             |
| Management Division        |     |    |                             |
| Training Program, WMP‑005, |     |    |                             |
| outlines the specific      |     |    |                             |
| requirements of the        |     |    |                             |
| internal training program. |     |    |                             |
|                            |     |    |                             |
| **Location:** (On file by  |     |    |                             |
| the site Central Training  |     |    |                             |
| Office, Waste Management   |     |    |                             |
| Division Training Program) |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **14. Emergency            |     |    |                             |
| Response:**                |     |    |                             |
|                            |     |    |                             |
| Waste Management Division  |     |    |                             |
| personnel are not trained  |     |    |                             |
| as emergency responders.   |     |    |                             |
| In the event of an         |     |    |                             |
| emergency, all Waste       |     |    |                             |
| Management Division staff  |     |    |                             |
| shall react to emergencies |     |    |                             |
| as outlined in the [Waste  |     |    |                             |
| Management Division Local  |     |    |                             |
| Emergency                  |     |    |                             |
| Plan]{.underline},         |     |    |                             |
| WMP-009.                   |     |    |                             |
|                            |     |    |                             |
| **Location:**              |     |    |                             |
| ([http://Waste Management  |     |    |                             |
| Division Local Emergency   |     |    |                             |
| Plan-WMP-009]())           |     |    |                             |
+----------------------------+-----+----+-----------------------------+
| **Authorization**          |     | ** |                             |
|                            |     | Da |                             |
|                            |     | te |                             |
|                            |     | ** |                             |
+----------------------------+-----+----+-----------------------------+
| **Appropriate management** |     |    |                             |
+----------------------------+-----+----+-----------------------------+
|                            |     |    |                             |
+----------------------------+-----+----+-----------------------------+

## Completing the title section of the environmental management program template (see Table 3) {#completing-the-title-section-of-the-environmental-management-program-template-see-table-3 .sub1}

1.  Sites may approach the creation of EMPs from different perspectives.
    They may develop one for each significant environmental aspect
    (identified in Phase I); they may develop one for each objective and
    target (also developed in Phase I); they may develop them for
    activities that contain significant environmental aspects; and, they
    may even develop them for facilities with many significant
    environmental aspects. Whatever approach sites use should suit their
    operations and make best use of existing programs. In the example
    depicted above, the EMP is developed for a specific objective, which
    is linked to the reduction of an aspect - Regulated Industrial
    Waste. Other EMPs may be developed to address aspects such as---

-   spills,

-   energy conservation,

-   water effluents, and

-   air emissions.

2.  In large facilities, or in instances where environmental aspects
    have many contributing sources, it is useful to break the aspect
    down into specific types with their own goals, objectives and
    targets. Where such a breakdown already exists for a facility, it
    should be used. For example, the items in the above list might be
    further subdivided as follows.

-   Spills

    -   Spills from "refuelings"

    -   Spills from chemical storage

    -   Spills from operational activities

    -   Spills from waste disposal

    -   Etc.

    ```{=html}
    <!-- -->
    ```
    -   Energy conservation

    ```{=html}
    <!-- -->
    ```
    -   Building 101

    -   Offices

    -   Etc.

    ```{=html}
    <!-- -->
    ```
    -   Water Effluents

    ```{=html}
    <!-- -->
    ```
    -   Laboratory sinks

    -   Water treatment plant

    -   Etc.

    ```{=html}
    <!-- -->
    ```
    -   Air emissions

    ```{=html}
    <!-- -->
    ```
    -   Greenhouse gas

    -   Ozone-depleting (ODS) substances

    -   Radon

    -   Etc.

EMPs can be and may need to be created for each of these subcategories
of environmental aspects.

3.  A separate field in the title section of the template provides space
    for a document control code. The primary purpose of this code is to
    allow the completed EMP to be easily referenced in other documents.
    The team should follow the site's existing document control
    procedure to specify this code.

4.  The date field indicates when the EMP information was last updated.
    (Because references in the EMP may point to information contained in
    other documents, this date may reflect modifications to data located
    in those other documents.)

## Completing the body of the EMPs template (see Table 3) {#completing-the-body-of-the-emps-template-see-table-3 .sub1}

Field 1---Objectives

The objectives specified in this field are the same set of objectives
developed in Phase I, for each of the significant environmental aspects.
In this case, to "*maintain compliance with all applicable operational
and reporting requirements associated with waste pickup and storage,
waste treatment, offsite transportation of waste, and maintenance
activities."*

Field 2---Targets

The targets specified in this field are the same targets set in Phase I
and associated with the objective listed in Field 1. Like the
objectives, these targets can be simply transcribed into this field.

Field 3---Reasons for Significance

The information for this field comes from the analysis prepared in Phase
I, which provide the reasons that the particular aspect has been
designated a significant environmental aspect (e.g., on the basis of its
regulatory score, mission score or overall score).

Field 4---Potential Environmental/Organizational Impacts

The relevant information for this entry was also prepared in Phase I.
This entry describes or makes reference to a documents that describes
the potential environmental/organizational impacts deemed important
enough by the organization to make the aspect a significant
environmental aspect.

Field 5---Legal and Other Requirements

This field contains data on the specific legal and other requirements
that pertain to this significant aspect. The legal requirements are
usually the regulatory requirements that were found to apply to a given
environmental aspect during the significance analysis in Phase I.
However, there may also be other legal requirements, such as contractual
obligations and imposed restrictions (e.g., DOE directives or court
orders and injunctions). Other requirements may originate from
customers, neighbors, employee trade unions, commitments made by the
organization, or policies followed by appropriate management. (In an EMS
a legal requirements procedure should be implemented for collecting and
maintaining legal and other requirements associated with existing
aspects. This procedure is covered in Phase III of this Guide). There is
no need to enter the complete, word-for-word requirements in this field;
it is sufficient to provide a general reference to the legal requirement
and make reference to the location of specific site requirements, such
as an Internet link.

Field 6---Performance Indicators

The entries for this field are derived from the goals, objectives, and
targets described in Table 9 of Phase I. Performance indicators are used
to track progress toward achieving the goals, objectives, and targets. A
procedure for monitoring and measurement is a recommended EMS Element.
Performance indicators may be entered directly into the environmental
management program or referenced as in Table 3 of this appendix. Table 4
of this appendix provides an example of the types of indicators that can
be used. In all cases, performance indicators should be developed to
provide valuable information on the achievement of goals, objectives and
targets and on the success of the ISMS/EMS. Quantitative measures, such
as tons of waste reduced or dollars saved, should be used over
qualitative indicators whenever possible.

Table 4. Example of Performance Indicators (Field 6)

  ------------------------------------ ----------------------------------
  **Objectives**                       **Indicators**

  1\. Maintain compliance              1\. Compliance status as
                                       determined in compliance audit

  2\. Reduce energy consumption 10%    2\. Kilowatt hours as measured on
  next fiscal year                     all meters and aggregated for the
                                       enterprise

  3\. Recycle 50% of solid waste       3\. Either the weight or volume of
  generated                            solid waste generated

  **Targets**                          **Indicators**

  1.1 Achieve Ozone Depleting          1.1 Meeting deadlines in the
  substance substitution 2 years ahead elimination timetable
  of requirement                       

  2.1 Reduce energy consumption in     2.1 Kilowatt hours as measured on
  operations by 8% in next fiscal year meter in operations area

  2.2 Reduce energy consumption in     2.2 Kilowatt hours as measured on
  vehicle maintenance shop by 15% in   meter in vehicle maintenance shop
  next fiscal year.                    

  3.1 Recycle 70% of office paper      3.1 Weight of recycled paper
                                       compared to weight of paper used

  3.2 Recycle 50 tons of glass         3.2 Weight of glass packaged for
                                       pickup by recycling firm
  ------------------------------------ ----------------------------------

Field 7---Environmental Management Program (EMP) Description

The EMP description provides a complete picture of the program that is
implemented to achieve the goals, objectives and targets. This provides
newly assigned program managers with useful background, so they can
continue to manage the EMP effectively. For example, Table 3 of this
appendix provides some basic background on the environmental management
program for maintaining compliance with regulated waste requirements. In
some cases, ISMS/EMS teams may find it advantageous to provide a much
more detailed description, including the specific actions to achieve the
goals, objectives, and targets. If a description of the EMP already
exists, it is sufficient to place a reference to it in this field, as
shown in Table 3 of this appendix.

Field 8---Operational Controls (OCs)

Operational controls are applied to activities, products, or services
that have environmental aspects in order to prevent potential impacts
from occurring. Operational controls can be engineering controls (e.g.,
valves, vessels, alarms) or administrative controls (e.g., protocols,
standing procedures, inspections) and are among the most essential
elements of an EMP. Without fully implemented operational controls, the
organization is not likely to maintain compliance with regulations or to
achieve its goals, objectives, and targets. Because of their importance,
it is recommended that a separate template be used to specify
operational controls (discussed in section B.4 below). The entry in the
operational control field of an EMP should therefore reference the
operational control templates associated with that EMP. It is more than
likely that operational controls already exist for all major
environmental releases at the site.

Field 9---Budget (Resources)

No program can be effectively executed without resources. The
information in this field describes those resources. For most programs,
the information here will consist of a reference to the organizational
budget or overhead account that allocates funds to the program.

Field 10---Structure, Authorities, Responsibilities

This field identifies those individuals with specific EMP
responsibilities. ISMS/EMS duties may be specified in individual job
descriptions such as the roles, responsibilities, accountabilities, and
authorities described in Table 5 of this appendix. ISMS/EMS duties
should be specified in the job descriptions for all job types, not just
the environmental positions. It is sufficient to reference these
descriptions. Specific tasks may also be assigned to individuals to
implement the EMP. Designated responsibilities relate to the programs,
objectives, targets, performance indicators, or any other part of the
environmental management program that requires some action or oversight.
An example of how this might be accomplished for certain goals,
objectives and targets is presented in the example for field 10 in Table
5 of this appendix.

The list of tasks in Table 5 of this appendix matches the commitments
and expectations stated in the goals, objectives, and targets and in the
performance indicators. This match-up can be used to test entries in
this field; for example, do the entries detail the tasks needed to
achieve the goals, objectives and targets, and to monitor performance
indicators? The information included here about the person responsible
for accomplishing each task can be either the name or the organizational
title of the individual accountable for that particular task.

Field 11---Records

This field generally provides a reference to the fact that records are
to be maintained in accordance with site policies and procedures. A
reference to the location of the records should also be included.

Field 12---Documents

This field references a list of the documents needed to execute the
environmental management program including documents that are referenced
or implied in other fields (often provided in the ISMS/EMS description).
These are documents that provide instructions and guidance to the
employees of the organization on how to achieve the goals, objectives,
and targets. The following are examples of the types of documents that
might be listed or referenced in field 12 of the environmental
management program template for a waste management division at a DOE
site.

-   The environmental management program description (if this is lengthy
    and is not already included in the template).

-   Documents relating to operational and reporting requirements for
    waste pickup and storage, waste treatment, offsite transportation of
    disposal, or maintenance activities.

-   Documents that specify any other operational controls (e.g., the
    operational control template associated with this environmental
    management program).

Table 5. Example of completed field 10 (Structure, Authorities,
Responsibilities)

  -----------------------------------------------------------------------
  **Tasks**                          **Persons Responsible**
  ---------------------------------- ------------------------------------
  Develop program to maintain        Regulatory expert
  compliance with ODS regulations    

  Implement program to maintain      \(a\) Manufacturing engineer, for
  compliance with OD substance       manufacturing area\
  regulations                        (b) Facilities engineer, for all
                                     other applications (e.g., chillers,
                                     air conditioning)

  Replace ODS in manufacturing       Manufacturing engineer

  Replace ODS in chillers            Facilities engineer

  Replace ODS in air-conditioning    Facilities engineer

  Establish contractual relation     Purchasing manager
  with dealers to sell OD substances 

  Audit compliance with ODS          Compliance audit manager
  regulations                        

  Ensure commitments to replace ODS  General manager of operations
  are met and contract with ODS      
  leader is established.             
  -----------------------------------------------------------------------

The following list shows potential environmental management program
objectives, targets, and performance indicators for ozone depleting
substances (ODSs). Below that is the list of the tasks needed to address
these objectives, targets, and performance indicators and the
individuals responsible for each task.

> *Objectives*

1.  Comply with regulations for ODSs.

2.  Replace 100 percent of ODSs within 3 years.

3.  Obtain market value for recycled ODSs from authorized dealers.

> *Targets*

1.  Implement program to ensure compliance with regulatory requirements
    for ODSs.

2.  Replace ODSs in manufacturing within 1 year.

3.  Replace ODSs in chillers within 2 years.

4.  Replace ODSs in air conditioners within 3 years.

5.  Establish contractual agreement to sell unneeded ODSs by March 31.

> *Performance Indicators*

1.  Periodic audit of ODSs compliance.

2.  Replace 100 percent of ODSs within 3 years.

3.  The date the contract for ODSs was established.

Field 13---Training

Field 13 of the environmental management program template contains
information on the competence and training of individuals responsible
for tasks and activities in the environmental management program. The
term "competence" does not imply an evaluation of a person's overall
abilities or inabilities; it is narrowly applied to the experience or
training of individuals assigned to accomplish specific tasks in the
environmental management program.

Competence is assessed on the basis of training, education, and/or
experience. The actual assessment of the competence of each "responsible
person" is performed by his or her manager or some other suitable
person. This official is asked to declare that the responsible person
whom he or she supervises is competent to accomplish the task that is
being assigned to him or her. Some examples of the types of information
that might be given to show the competence of an individual are provided
in Table 6 of this appendix.

Field 14---Emergency Response

This field contains a reference to the organization's emergency response
program. This program is usually well established in DOE facilities
although it must be reviewed to ensure that it contains contingencies
for incidents that have potential environmental impacts.

Other Fields

ISMS/EMS teams may wish to add other fields to the environmental
management program documentation.

1.  Operational Controls Template

    1.  Documenting Operational Controls

DOE sites have already implemented a vast array of technological and
administrative controls for their various operational activities.
Nevertheless, the operational control template is valuable for
documenting the details of operational controls, particularly if a new
operational control is being implemented for an existing or new
activity. The template ties together all the interrelated elements
needed to effectively implement the operational control. The operational
controls are integral to specific environmental management programs (as
described in Table 3 above), and the operational control template is
used to record information that would otherwise be entered into fields
of the environmental management program template. Therefore, an
operational control template should be linked to the environmental
management program template that it is associated with.

Table 6. Competence

  -----------------------------------------------------------------------
  **Responsible        **Basis of Competence**
  Person**             
  -------------------- --------------------------------------------------
  John Henry,          Completed training on Hazardous Waste Regulations
  regulatory expert    (RCRA training) in January of this year

  John Doe,            Attended course provided by vendor of new clean
  manufacturing        materials available for substitution in processes
  engineer             

  Jane Doe, facilities Extensive experience with previous employers with
  engineer             P2 process reengineering

  Sally Doe,           Extensive experience in buying and selling
  purchasing manager   chemicals and in dealing with recyclers

  Tom Doe, compliance  Extensive experience in compliance auditing. Has
  audit manager        discussed Hazardous Waste requirements with John
                       Henry and has included Hazardous Waste management
                       and improvement elements in audit criteria

  James Doe, general   Experience in managing operations with tasks
  manager of           similar to those required for the successful
  operations           execution of this program
  -----------------------------------------------------------------------

2.  Completing the Body of the Operational Controls Template (Table 7)

Table 7 of this appendix is an example of a completed operational
control template for operational controls associated with activities
that generate waste. This example comes from a facility at a DOE site.
It provides an illustration of how the operational control template
links relevant EMS elements that are specific to that operational
control.

**Table 7. Completed Operational Controls Template**

+-----------------+---+------------+------+---------------------------+
| **Operational   |   |            |      |                           |
| Controls        |   |            |      |                           |
| Template**      |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **A.            | * |            |      |                           |
| Significant     | * |            |      |                           |
| Environmental   | B |            |      |                           |
| Aspect:** Waste | . |            |      |                           |
| Generation      | O |            |      |                           |
|                 | b |            |      |                           |
|                 | j |            |      |                           |
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|                 | : |            |      |                           |
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|                 | . |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **C. Document   |   |            |      | **D. Date:** 05/15/2003   |
| Control Code:** |   |            |      |                           |
| EP-329-CSS      |   |            |      | **Revision Date:**        |
|                 |   |            |      | 05/15/2004                |
+-----------------+---+------------+------+---------------------------+
| **1. Source of  |   |            |      |                           |
| Aspect          |   |            |      |                           |
| (activities):** |   |            |      |                           |
|                 |   |            |      |                           |
| **-** Spray     |   |            |      |                           |
| Painting        |   |            |      |                           |
|                 |   |            |      |                           |
| \- Laboratory   |   |            |      |                           |
| use of          |   |            |      |                           |
| chemicals       |   |            |      |                           |
|                 |   |            |      |                           |
| \- Maintenance  |   |            |      |                           |
| operations      |   |            |      |                           |
|                 |   |            |      |                           |
| \- Management   |   |            |      |                           |
| of stored       |   |            |      |                           |
| chemicals       |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **2. Legal and  |   |            |      |                           |
| Other           |   |            |      |                           |
| Requirements    |   |            |      |                           |
| (specific to    |   |            |      |                           |
| activities):**  |   |            |      |                           |
|                 |   |            |      |                           |
| The following   |   |            |      |                           |
| requirements    |   |            |      |                           |
| are listed for  |   |            |      |                           |
| information     |   |            |      |                           |
| purposes. Refer |   |            |      |                           |
| to XYZ          |   |            |      |                           |
| Laborato        |   |            |      |                           |
| ry---Management |   |            |      |                           |
| Systems         |   |            |      |                           |
| Description:    |   |            |      |                           |
| Environmental   |   |            |      |                           |
| Managements     |   |            |      |                           |
| Systems (Site   |   |            |      |                           |
| internet        |   |            |      |                           |
| reference) for  |   |            |      |                           |
| the most        |   |            |      |                           |
| current list of |   |            |      |                           |
| environmental   |   |            |      |                           |
| permits,        |   |            |      |                           |
| regulations,    |   |            |      |                           |
| DOE directives, |   |            |      |                           |
| and other       |   |            |      |                           |
| requirements.   |   |            |      |                           |
|                 |   |            |      |                           |
| A. XYZ          |   |            |      |                           |
| Laboratory      |   |            |      |                           |
| (Site internet  |   |            |      |                           |
| reference)      |   |            |      |                           |
|                 |   |            |      |                           |
| B. Plant        |   |            |      |                           |
| Engineering     |   |            |      |                           |
| Operations &    |   |            |      |                           |
| Maintenance     |   |            |      |                           |
| Operational     |   |            |      |                           |
| Policies &      |   |            |      |                           |
| Procedures      |   |            |      |                           |
|                 |   |            |      |                           |
| C. State Air    |   |            |      |                           |
| Quality Permits |   |            |      |                           |
| #               |   |            |      |                           |
| 472002-943-4402 |   |            |      |                           |
| and             |   |            |      |                           |
| #               |   |            |      |                           |
| 47022-943-42203 |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **3.            |   |            |      |                           |
| Operational     |   |            |      |                           |
| Controls**      |   |            |      |                           |
| \[such as       |   |            |      |                           |
| technological,  |   |            |      |                           |
| operational,    |   |            |      |                           |
| procedural (and |   |            |      |                           |
| corresponding   |   |            |      |                           |
| written         |   |            |      |                           |
| controls, where |   |            |      |                           |
| app             |   |            |      |                           |
| licable)\]**:** |   |            |      |                           |
|                 |   |            |      |                           |
| \- Laboratory   |   |            |      |                           |
| Subject Areas   |   |            |      |                           |
| and             |   |            |      |                           |
| Environmental,  |   |            |      |                           |
| Safety and      |   |            |      |                           |
| Heath standards |   |            |      |                           |
| provide         |   |            |      |                           |
| L               |   |            |      |                           |
| aboratory-level |   |            |      |                           |
| operational     |   |            |      |                           |
| control         |   |            |      |                           |
| requirements.   |   |            |      |                           |
| The following   |   |            |      |                           |
| subject areas   |   |            |      |                           |
| are applicable  |   |            |      |                           |
| to the          |   |            |      |                           |
| significant     |   |            |      |                           |
| environmental   |   |            |      |                           |
| aspects         |   |            |      |                           |
| associated with |   |            |      |                           |
| these           |   |            |      |                           |
| activities:     |   |            |      |                           |
|                 |   |            |      |                           |
| \> [Hazardous   |   |            |      |                           |
| Waste           |   |            |      |                           |
| Management      |   |            |      |                           |
| Subject         |   |            |      |                           |
| Ar              |   |            |      |                           |
| ea]{.underline} |   |            |      |                           |
|                 |   |            |      |                           |
| \> [Storage and |   |            |      |                           |
| Transfer of     |   |            |      |                           |
| Hazardous       |   |            |      |                           |
| Materia         |   |            |      |                           |
| ls]{.underline} |   |            |      |                           |
|                 |   |            |      |                           |
| \> [Radiation   |   |            |      |                           |
| Work            |   |            |      |                           |
| Permi           |   |            |      |                           |
| ts]{.underline} |   |            |      |                           |
|                 |   |            |      |                           |
| \- The          |   |            |      |                           |
| following       |   |            |      |                           |
| Environmental,  |   |            |      |                           |
| Safety and      |   |            |      |                           |
| Health          |   |            |      |                           |
| Standards       |   |            |      |                           |
| provide         |   |            |      |                           |
| additional      |   |            |      |                           |
| operational     |   |            |      |                           |
| controls in the |   |            |      |                           |
| area of         |   |            |      |                           |
| inspections and |   |            |      |                           |
| planning        |   |            |      |                           |
| nonroutine      |   |            |      |                           |
| work:           |   |            |      |                           |
|                 |   |            |      |                           |
| \> [Standard    |   |            |      |                           |
| 2.1.            |   |            |      |                           |
| 0.]{.underline} |   |            |      |                           |
| Departmental    |   |            |      |                           |
| Environmental,  |   |            |      |                           |
| Safety, and     |   |            |      |                           |
| Health          |   |            |      |                           |
| Inspections     |   |            |      |                           |
|                 |   |            |      |                           |
| \> [Standard    |   |            |      |                           |
| 3.1.            |   |            |      |                           |
| 6.]{.underline} |   |            |      |                           |
| Work Planning   |   |            |      |                           |
| and Control for |   |            |      |                           |
| Operations      |   |            |      |                           |
| requires a work |   |            |      |                           |
| permit for      |   |            |      |                           |
| operations like |   |            |      |                           |
| site            |   |            |      |                           |
| p               |   |            |      |                           |
| reparation/tree |   |            |      |                           |
| clearing, and   |   |            |      |                           |
| evaluates waste |   |            |      |                           |
| generation,     |   |            |      |                           |
| sensi           |   |            |      |                           |
| tive/endangered |   |            |      |                           |
| species,        |   |            |      |                           |
| sensitive       |   |            |      |                           |
| habitat, and    |   |            |      |                           |
| pine barrens    |   |            |      |                           |
| issues (among   |   |            |      |                           |
| others).        |   |            |      |                           |
|                 |   |            |      |                           |
| \- Project      |   |            |      |                           |
| Specific Health |   |            |      |                           |
| and Safety      |   |            |      |                           |
| Plans evaluate  |   |            |      |                           |
| safety and      |   |            |      |                           |
| environmental   |   |            |      |                           |
| concerns        |   |            |      |                           |
| associated with |   |            |      |                           |
| project         |   |            |      |                           |
| implementation  |   |            |      |                           |
| and prescribe   |   |            |      |                           |
| appropriate     |   |            |      |                           |
| protective      |   |            |      |                           |
| measures.       |   |            |      |                           |
|                 |   |            |      |                           |
| Batteries are   |   |            |      |                           |
| managed in      |   |            |      |                           |
| accordance with |   |            |      |                           |
| the guide       |   |            |      |                           |
| listed on the   |   |            |      |                           |
| "How do I       |   |            |      |                           |
| manage this     |   |            |      |                           |
| waste stream"   |   |            |      |                           |
| web page (Site  |   |            |      |                           |
| internet        |   |            |      |                           |
| reference)      |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| *Control and    |   |            |      | *Legal and Other          |
| Description*    |   |            |      | Requirements (see field   |
|                 |   |            |      | 2)*                       |
+-----------------+---+------------+------+---------------------------+
| 1.0 XYZ         |   |            |      | **A**                     |
| Laboratory      |   |            |      |                           |
| Requirements    |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.1 Facility    |   |            |      | **A**                     |
| Use Agreements  |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.2 Liquid      |   |            |      | **A**                     |
| effluents       |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.3 Air         |   |            |      | **A, C**                  |
| Emissions       |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.4 Waste       |   |            |      | **A.1**                   |
| Disposal        |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.5 Training    |   |            |      | **A**                     |
+-----------------+---+------------+------+---------------------------+
| 2.0 Operational |   |            |      | **B**                     |
| Procedures      |   |            |      |                           |
| (Site internet  |   |            |      |                           |
| reference)      |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **4.            |   |            |      |                           |
| Maintenance     |   |            |      |                           |
| plans for the   |   |            |      |                           |
| operational     |   |            |      |                           |
| controls:**     |   |            |      |                           |
|                 |   |            |      |                           |
| \- Maintenance  |   |            |      |                           |
| Management      |   |            |      |                           |
| Center:         |   |            |      |                           |
| Preventive      |   |            |      |                           |
| Maintenance     |   |            |      |                           |
| Program.        |   |            |      |                           |
|                 |   |            |      |                           |
| \- Procedural   |   |            |      |                           |
| Operational     |   |            |      |                           |
| controls        |   |            |      |                           |
| \[subject       |   |            |      |                           |
| areas, ES&H     |   |            |      |                           |
| standards,      |   |            |      |                           |
| Standard        |   |            |      |                           |
| Operating       |   |            |      |                           |
| Procedures      |   |            |      |                           |
| (SOPs)\] are    |   |            |      |                           |
| maintained in   |   |            |      |                           |
| accordance with |   |            |      |                           |
| the             |   |            |      |                           |
| Laboratory-wide |   |            |      |                           |
| procedures and  |   |            |      |                           |
| guidelines      |   |            |      |                           |
| subject area.   |   |            |      |                           |
|                 |   |            |      |                           |
| \- Since all    |   |            |      |                           |
| operational     |   |            |      |                           |
| controls        |   |            |      |                           |
| identified are  |   |            |      |                           |
| either          |   |            |      |                           |
| procedural or   |   |            |      |                           |
| operator aids,  |   |            |      |                           |
| there is no     |   |            |      |                           |
| need for a plan |   |            |      |                           |
| to maintain     |   |            |      |                           |
| controls due to |   |            |      |                           |
| a shutdown.     |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **5. Actions to |   |            |      |                           |
| be taken if     |   |            |      |                           |
| controls        |   |            |      |                           |
| fail:**         |   |            |      |                           |
|                 |   |            |      |                           |
| \- Implement    |   |            |      |                           |
| the Local       |   |            |      |                           |
| Emergency Plan. |   |            |      |                           |
|                 |   |            |      |                           |
| \- Comply with  |   |            |      |                           |
| Spill Response  |   |            |      |                           |
| subject area.   |   |            |      |                           |
|                 |   |            |      |                           |
| \- Implement    |   |            |      |                           |
| the contingency |   |            |      |                           |
| plan for the    |   |            |      |                           |
| 90-day          |   |            |      |                           |
| Accumulation    |   |            |      |                           |
| Area if         |   |            |      |                           |
| applicable      |   |            |      |                           |
|                 |   |            |      |                           |
| \- Contact      |   |            |      |                           |
| appropriate     |   |            |      |                           |
| authority,      |   |            |      |                           |
| Building        |   |            |      |                           |
| Maintenance &   |   |            |      |                           |
| Services        |   |            |      |                           |
| General         |   |            |      |                           |
| Supervisor,     |   |            |      |                           |
| Cabinetry &     |   |            |      |                           |
| Paint           |   |            |      |                           |
| Supervisors,    |   |            |      |                           |
| Multitrade      |   |            |      |                           |
| Supervisor      |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **6. Records:** |   |            |      |                           |
|                 |   |            |      |                           |
| \- Control and  |   |            |      |                           |
| Record          |   |            |      |                           |
| Description:    |   |            |      |                           |
|                 |   |            |      |                           |
| \- 1.1 90-Day   |   |            |      |                           |
| Area Log & SAA  |   |            |      |                           |
| Location List   |   |            |      |                           |
| (FUA)           |   |            |      |                           |
|                 |   |            |      |                           |
| \- 1.4 Process  |   |            |      |                           |
| Knowledge form  |   |            |      |                           |
|                 |   |            |      |                           |
| \- 1.5 Training |   |            |      |                           |
| Records         |   |            |      |                           |
|                 |   |            |      |                           |
| \- 2.0 Tier 1   |   |            |      |                           |
| Documents, Tier |   |            |      |                           |
| 1 &             |   |            |      |                           |
| Self-Assessment |   |            |      |                           |
| Inspection      |   |            |      |                           |
| Records,        |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **7.            |   |            |      |                           |
| Re              |   |            |      |                           |
| sponsibility:** |   |            |      |                           |
|                 |   |            |      |                           |
| \- To ensure    |   |            |      |                           |
| controls are in |   |            |      |                           |
| place           |   |            |      |                           |
|                 |   |            |      |                           |
| \- To ensure    |   |            |      |                           |
| controls keep   |   |            |      |                           |
| working         |   |            |      |                           |
|                 |   |            |      |                           |
| \- To take      |   |            |      |                           |
| action when     |   |            |      |                           |
| controls fail   |   |            |      |                           |
|                 |   |            |      |                           |
| \- To create    |   |            |      |                           |
| and keep        |   |            |      |                           |
| records         |   |            |      |                           |
| relative to     |   |            |      |                           |
| operational     |   |            |      |                           |
| controls        |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **Control &     |   |            |      | **Responsible**           |
| Description**   |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| ## E            |   |            |      | Office Manager            |
| nsure laborator |   |            |      |                           |
| y-level control |   |            |      |                           |
| s (subject area |   |            |      |                           |
| s and standards |   |            |      |                           |
| ) are in place  |   |            |      |                           |
|  {#ensure-labor |   |            |      |                           |
| atory-level-con |   |            |      |                           |
| trols-subject-a |   |            |      |                           |
| reas-and-standa |   |            |      |                           |
| rds-are-in-plac |   |            |      |                           |
| e .sub-heading} |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.0 All staff   |   |            |      | All staff                 |
| are empowered   |   |            |      |                           |
| to Stop Work    |   |            |      |                           |
| and/or initiate |   |            |      |                           |
| emergency       |   |            |      |                           |
| actions in the  |   |            |      |                           |
| event controls  |   |            |      |                           |
| fail            |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.0 Maintain    |   |            |      | Central Training Office   |
| training        |   |            |      |                           |
| records         |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.0 Storage &   |   |            |      | 90-day Accumulation Area  |
| transfer of     |   |            |      | Coordinator               |
| waste,          |   |            |      |                           |
| hazardous       |   |            |      |                           |
| material. See   |   |            |      |                           |
| R2A2 profile    |   |            |      |                           |
| (Site internet  |   |            |      |                           |
| reference)      |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.0 Maintain    |   |            |      | Generator and/or Line     |
| Training &      |   |            |      | Manager                   |
| Qualifications  |   |            |      |                           |
| as Waste        |   |            |      |                           |
| Generator       |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.0 Maintain    |   |            |      | EMS Coordinator           |
| Operational     |   |            |      |                           |
| Control         |   |            |      |                           |
| Templates       |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.1 Facility    |   |            |      | Building Manager          |
| Use Agreements  |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.4 Coordinate  |   |            |      | Waste Management          |
| waste disposal. |   |            |      | Representative (WMR)      |
| Provide         |   |            |      |                           |
| technical       |   |            |      |                           |
| assistance to   |   |            |      |                           |
| manage waste in |   |            |      |                           |
| compliance with |   |            |      |                           |
| requirements.   |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.5 Waste &     |   |            |      | General Supervisor,       |
| materials       |   |            |      | Cabinetry & Paint         |
| storage,        |   |            |      | Supervisor,               |
| handling,       |   |            |      | Cabinetmakers, Model      |
| generating,     |   |            |      | Makers Cabinetmaker       |
| disposal,       |   |            |      | Apprentice, Sign Painter, |
| transport. See  |   |            |      | General Supervisor        |
| R2A2 profile    |   |            |      |                           |
| (Site internet  |   |            |      |                           |
| reference)      |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 2.0 Initiate    |   |            |      | Work Controls             |
| pork planning   |   |            |      | Coordinator, General      |
| and control for |   |            |      | Supervisor, Cabinetry &   |
| operation       |   |            |      | Paint Supervisor          |
| standard        |   |            |      |                           |
| (1.3.6) and     |   |            |      |                           |
| involve staff   |   |            |      |                           |
| with            |   |            |      |                           |
| appropriate     |   |            |      |                           |
| environmental   |   |            |      |                           |
| expertise       |   |            |      |                           |
| (ECR).          |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 2.0 Participate |   |            |      | Environmental Compliance  |
| in work         |   |            |      | Representative (ECR),     |
| planning and    |   |            |      | General Supervisor,       |
| health and      |   |            |      | Cabinetry & Paint         |
| safety plan     |   |            |      | Supervisor                |
| preparation.    |   |            |      |                           |
| Identify legal  |   |            |      |                           |
| and other       |   |            |      |                           |
| requirements    |   |            |      |                           |
| applicable to   |   |            |      |                           |
| planned work    |   |            |      |                           |
| and lead effort |   |            |      |                           |
| to develop      |   |            |      |                           |
| solutions.      |   |            |      |                           |
| Participate in  |   |            |      |                           |
| surveillance    |   |            |      |                           |
| activities.     |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| 2.0 Participate |   |            |      | Contractor Services,      |
| in work         |   |            |      | General Supervisor,       |
| planning        |   |            |      | Cabinetry & Paint         |
|                 |   |            |      | Supervisor,               |
|                 |   |            |      | Cabinetmakers, Model      |
|                 |   |            |      | Makers, Cabinetmaker      |
|                 |   |            |      | Apprentice, Sign Painter, |
|                 |   |            |      | General Supervisor        |
+-----------------+---+------------+------+---------------------------+
| 2.0 Tier 1      |   |            |      | Tier 1 Inspection         |
| Documentation   |   |            |      | Committee                 |
+-----------------+---+------------+------+---------------------------+
| 2.0 Tier 1      |   |            |      | Safety Committee          |
| Self-Assessment |   |            |      |                           |
| & Environmental |   |            |      |                           |
| Compliance      |   |            |      |                           |
| Assessment      |   |            |      |                           |
| Documents       |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **8.            |   |            |      |                           |
| Competency**    |   |            |      |                           |
| (as evidenced   |   |            |      |                           |
| by training,    |   |            |      |                           |
| experience, or  |   |            |      |                           |
| education.)     |   |            |      |                           |
| (Note:          |   |            |      |                           |
| Individuals     |   |            |      |                           |
| implementing    |   |            |      |                           |
| operational     |   |            |      |                           |
| controls are to |   |            |      |                           |
| be trained to a |   |            |      |                           |
| level           |   |            |      |                           |
| commensurate    |   |            |      |                           |
| with their      |   |            |      |                           |
| r               |   |            |      |                           |
| esponsibility): |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+
| **Title**       |   | **Required |      | **8.2 Competence**        |
|                 |   | person**   |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.0 ABMS        |   | General    |      | \- Completion of required |
| subject area    |   | S          |      | training for assigned     |
|                 |   | upervisor, |      | craft code                |
|                 |   |            |      |                           |
|                 |   | Ca         |      | \- Plant engineering O7M  |
|                 |   | binetmaker |      | procedure review for      |
|                 |   |            |      | relevant craft code       |
|                 |   | Ca         |      |                           |
|                 |   | binetmaker |      |                           |
|                 |   | Apprentice |      |                           |
|                 |   | Model      |      |                           |
|                 |   | Maker Sign |      |                           |
|                 |   | Painter    |      |                           |
+-----------------+---+------------+------+---------------------------+
| 1.1 Facility    |   | Building   |      | \- Building Manager       |
| Use Agreements  |   | Manager    |      | Training                  |
+-----------------+---+------------+------+---------------------------+
| 2.0 Operational |   | S          |      | \- RCRA 90 day Area       |
| Procedure       |   | upervisor, |      | Manager (HP-90 DAY)       |
|                 |   | Cabinet    |      |                           |
|                 |   | Shop       |      | \- Hazardous Waste        |
|                 |   |            |      | Generator (HP-RCGEN#)     |
|                 |   |            |      |                           |
|                 |   |            |      | \- Environmental          |
|                 |   |            |      | Protection for General    |
|                 |   |            |      | Employees (GE-ENV-GET)    |
|                 |   |            |      |                           |
|                 |   |            |      | \- Emergency Planning     |
|                 |   |            |      | Response (GE‑EMERGPLAN)   |
|                 |   |            |      |                           |
|                 |   |            |      | \- Hazard communication   |
|                 |   |            |      | (IND 200R)                |
+-----------------+---+------------+------+---------------------------+
| 2.0 Operational |   | Cab        |      | Environmental Protection  |
| Procedure       |   | inetmakers |      | for General Employees     |
|                 |   |            |      | (GE-ENV-GET)              |
|                 |   | Finishers  |      |                           |
|                 |   |            |      | Emergency Planning and    |
|                 |   | Sign       |      | Response (GE‑EMERGPLAN)   |
|                 |   | Painter    |      |                           |
|                 |   |            |      | Hazard Communication      |
|                 |   | Model      |      | (IND200R)                 |
|                 |   | Maker      |      |                           |
+-----------------+---+------------+------+---------------------------+
| **              |   |            | **Da |                           |
| Authorization** |   |            | te** |                           |
+-----------------+---+------------+------+---------------------------+
| **Appropriate   |   |            |      |                           |
| management**    |   |            |      |                           |
+-----------------+---+------------+------+---------------------------+

## Operational Controls Title Section {#operational-controls-title-section .sub1}

Field A---Significant Environmental Aspect

Although operational controls are developed for specific activities,
products or services, it is useful to link them back to the original
significant environmental aspect that they will address.

Field B---Objectives

It is also useful to link the operational control to the objective to
which it applies. The significant aspects and the goals, objectives and
targets in the EMS provide the basis for both the environmental
management programs and the operational controls.

Field C---Document Control Code

This code is simply one approach for managing the various documents that
exist under the ISMS/EMS. Using a document control code facilitates
cross-referencing and database searches.

Field D---Date

The date tells users when the operational control was developed; the
revision date prescribes when it should be reviewed and revised. It may
also be useful to insert the name of the person or persons who completed
the operational control so that queries can be referred to them.

Field 1---Source of Aspect (activities)

Field 1 contains all of the activities to which the operational control
applies. The desired result is to apply the appropriate control to the
individual activity. For example, if laboratory use of chemicals is the
activity and waste generation is the aspect, it is likely that a number
of actual laboratory activities might result in waste generation, such
as disposing of spent samples, collecting samples in the field, and
analyzing samples. These individual activities generate waste and must
be controlled to avoid the mismanagement and potential impacts of that
waste. Different controls will be appropriate for these different
activities.

Field 2---Legal and Other Requirements (specific activities)

It is not always necessary to identify the legal and other requirements
related to the operational controls. Table 7 addresses regulatory
compliance as these in particular are closely connected to the
operational controls specified here.

Field 3---Operational Controls (technological, administrative, etc.)

For any significant aspect, operational controls can be developed for
all of its processes, activities that comprise a process, and individual
tasks that comprise an activity. The operational control reduces the
probability of negative aspects, enhances positive aspects, and furthers
ES&H objectives set by the organization. Table 7 shows that operational
controls can be linked to individual legal and other requirements. Table
8, below, illustrates some alternative approaches for completing field
3.

Field 4---Maintenance plans for the operational controls

This field describes or points to plans to maintain the operational
controls (i.e., keep them updated and relevant to operations and
activities). Table 9 of this appendix shows that operational controls
can be maintained by several functions in the organization that are
referenced in field 4. Alternatively, the ISMS/EMS team can describe the
actual approaches that will be taken to maintain operational controls as
exemplified in Table 9 of this appendix.

Table 8. Examples of Operational Controls That Might Be Designated\
for a Variety of Sources

+-----------------------------+----------------------------------------+
| **Source for Aspect**       | **Operational Controls**               |
+-----------------------------+----------------------------------------+
| Analysis of samples         | 1.  Chemical Hygiene Plan (steps . . . |
|                             |     ); annual internal inspection by   |
|                             |     Region III SHEM Managers           |
|                             |                                        |
|                             | 2.  Triennial external inspection by   |
|                             |     EPA Headquarters                   |
+-----------------------------+----------------------------------------+
| Use of solvents             | 3.  Chemical Hygiene Plan (steps . . . |
|                             |     .); storm drain system and catch   |
|                             |     basin designed to contain          |
|                             |     uncontrolled spill; annual         |
|                             |     Facility Inspection Checklist in   |
|                             |     SPCCP Appendix D                   |
+-----------------------------+----------------------------------------+
| Change oil in pumps         | 4.  Inspection, use of SOPs, log book  |
|                             |     for inspection and oil change      |
+-----------------------------+----------------------------------------+
| 1.  Storage tank            | 5.  Place the storage tank aboveground |
|                             |     with secondary containment. Also,  |
|                             |     double-walled pipes to and from    |
|                             |     the tank. (Reference to storage    |
|                             |     tank engineering specs)            |
+-----------------------------+----------------------------------------+
| 5\. Overfilling or poor     | 6.  SOP for the filling of storage     |
| operation of equipment      |     tanks including use of spill       |
|                             |     flange and log book to record      |
|                             |     filling operations                 |
+-----------------------------+----------------------------------------+

Table 9. Examples of Maintenance Plans That Might Be Developed\
for a Variety of Operational Controls

+-------------------------------------+--------------------------------+
| **Operational Controls**            | **Maintenance Plan**           |
+-------------------------------------+--------------------------------+
| 1.  Chemical Hygiene Plan (steps .  | 1.  Periodic review of         |
|     . . .); annual internal         |     internal and external      |
|     inspection by Region III SHEM   |     inspection findings;       |
|     Managers; triennial external    |     lessons learned procedure  |
|     inspection by EPA Headquarters  |     followed, and suitable     |
|                                     |     adjustments made.          |
+-------------------------------------+--------------------------------+
| 2.  Chemical Hygiene Plan (steps .  | 2.  Review of inspection       |
|     . . .); storm drain system and  |     findings, including        |
|     catch basin designed to contain |     effectiveness of storm     |
|     uncontrolled spills; Annual     |     drain system and           |
|     Facility Inspection Checklist   |     adjustments made           |
|     in SPCC                         |     accordingly                |
+-------------------------------------+--------------------------------+
| 3.  Inspection, use of SOPs, log    | 3.  Periodic review of logbook |
|     book for inspection and oil     |     and SOPs                   |
|     change                          |                                |
+-------------------------------------+--------------------------------+
| 4.  Place the storage tank above    | 4.  Inspect storage tank and   |
|     ground with secondary           |     piping periodically and do |
|     containment. Also,              |     scheduled maintenance      |
|     double-walled pipes to and from |     (reference to inspection   |
|     the tank (reference to storage  |     and maintenance procedure  |
|     tank engineering specs).        |     for fuel tanks and piping) |
+-------------------------------------+--------------------------------+
| 5.  SOP for filling storage tanks,  | 5.  Periodic review of SOPs    |
|     including use of spill flange   |     for filling tanks          |
|     and log book to record filling  |                                |
|     operations.                     |                                |
+-------------------------------------+--------------------------------+

Field 5---Actions to be taken if controls fail

Field 5 provides information on the countermeasures to take if a
significant environmental aspect occurs despite implementation of
operational controls. Although some of these measures may also be
included in the organization's emergency response and preparedness plan,
the purpose here is to address the limited and less dramatic events that
do not trigger an emergency response. For example, a plan could be
developed to deal with small spills or waste discharges. As required by
the Clean Water Act, this need could be met through the SPCC. If the
organization is not subject to regulatory requirements for such plans,
it may want to create them for inclusion in its ISMS/EMS. (A reference
to the existing SPCC will suffice as an entry for this field.)

Field 6---Records

Field 6 captures information about the records to be generated regarding
use of operational controls. As with the environmental management
program, the operational control template can simply include references
that indicate the record names and their location within the
organization. Following are examples of operational control records
typically generated:

-   records of maintenance on operational controls,

-   records of actions taken in cases of control failures,

-   records of changes made to operational controls, and

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```
-   logs that record the functioning of operational controls

Field 7---Responsibility

An EMP specifies a list of tasks and persons accountable for achieving
the program's goals, objectives, and targets, and monitoring performance
indicators. Field 7 of the operational control template similarly
provides a list of names of those responsible for operational controls.
Some of these individuals may be the same as those designated in the
EMP. The types of responsibilities outlined in the operational control
template are shown in Table 7 and may also include the following.

-   Ensuring that controls are in place.

-   Ensuring that controls keep working as intended.

-   Taking action when controls fail.

```{=html}
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```
-   Creating and/or keeping records relative to operational controls.

## *Field 8---Competency* {#field-8competency .sub-heading}

Field 8 of the operational control template provides information on the
competencies expected of the persons listed in field 7. As with
environmental management programs, competence is not a judgment
regarding a person's total ability or inability. The concept is applied
only to the person's ability to deal with the assigned operational
controls. The value in making this determination is that it compels an
evaluation by management that will more likely result in the right
person being assigned to a task that is suitable to his or her current
expertise (see also Table 6).

1.  Documenting Integrated Safety Management System/Environmental
    Management System Procedures

Standard operating procedures are an essential element of any management
system. It is highly recommended that sites document these procedures,
as well as other procedures that are repeatedly carried out in the
ISMS/EMS. By documenting common procedures, sites ensure that they are
carried out consistently and reliably. Table 10 lists all the procedures
required by DOE O 450.1, as well as the procedures that are recommended.
Sites should consider documenting all these procedures.

Table 10 can also be used to identify any existing procedures used at
the site that would apply to the ISMS/EMS. Once these EMS procedures
have been identified, ensure that they *address all EMS requirements* by
comparing them to the list of procedures in Table 10**.** If any of the
EMS elements listed in Table 10 of this appendix are not addressed by an
existing procedure, the ISMS/EMS team should develop a new procedure
based on the templates provided in Table 11. An example of how these
templates may be used by ISMS/EMS teams to develop a new procedure is
provided below.

Table 10. EMS Element Procedures Required by DOE O 450.1

+-----------------+-----------------------------+----------------------+
| > **Management  | **DOE O 450.1 Procedures**  | ## ISMS Links {#isms |
| > System        |                             | -links .sub-heading} |
| > Elements to   |                             |                      |
| > Include in    |                             |                      |
| > Standard      |                             |                      |
| > Operating/    |                             |                      |
| >               |                             |                      |
|  Administrative |                             |                      |
| > Procedures    |                             |                      |
| > for           |                             |                      |
| > ISMS/EMS**    |                             |                      |
+=================+=============================+======================+
| Identifying     | Procedure Required          | "hazards . . . are   |
| Significant     | \[§4.a.(2)\] "procedures .  | identified,          |
| Environmental   | . . to identify activities  | analyzed, and        |
| Aspects         | with significant            | categorized"---DOE   |
|                 | environmental impacts"      | P 450.4              |
+-----------------+-----------------------------+----------------------+
| > Identifying   | Procedure Recommended       | "applicable . . .    |
| > Legal and     | \[§4.a.(1)(c)\] "programs   | requirements are     |
| > Other         | for ... compliance with     | identified . . .     |
| > Requirements  | applicable environmental    | ."---DOE P 450.4     |
|                 | protection requirements"    |                      |
+-----------------+-----------------------------+----------------------+
| > Establishing  | Procedure Recommended       | DEAR Clause          |
| > Measurable    | \[§4.a.(2)\] "includes      | "establish,          |
| > Environmental | measurable environmental    | document, and        |
| > Goals,        | goals, objectives and       | implement            |
| > Objectives    | targets that are reviewed   | performance          |
| > and Targets   | annually and updated when   | objectives,          |
|                 | appropriate"                | performance          |
|                 |                             | measures, and        |
|                 |                             | commitments"---DOE P |
|                 |                             | 450.4                |
|                 |                             |                      |
|                 |                             | "develop ES&H        |
|                 |                             | performance          |
|                 |                             | objectives,          |
|                 |                             | measures, and        |
|                 |                             | expectations" ---DOE |
|                 |                             | P 450.5              |
+-----------------+-----------------------------+----------------------+
| Determining     | Procedure Required          | "develop and         |
| Operational     | \[§4.a.(2)\] "procedures to | implement hazard     |
| Controls        | . . . manage, control and   | controls"---DOE P    |
|                 | mitigate the impacts of . . | 450.4                |
|                 | . activities \[with         |                      |
|                 | significant environmental   |                      |
|                 | impacts\]"                  |                      |
+-----------------+-----------------------------+----------------------+
| > Determining   | Procedure Required          | "develop and         |
| > Environmental | \[§4.a.(2)\] "procedures .  | implement hazard     |
| > Management    | . . to manage, control, and | controls"---DOE P    |
| > Programs      | mitigate the impacts of . . | 450.4                |
|                 | . activities \[with         |                      |
|                 | significant environmental   |                      |
|                 | impacts\]"                  |                      |
+-----------------+-----------------------------+----------------------+
| > Environmental | Procedure Required          | "controls are        |
| > Training of   | \[§4.a.(2)\] "training to   | implemented;"        |
| > Employees     | identify activities with    |                      |
|                 | significant environmental   | "personnel shall     |
|                 | impacts, to manage,         | possess the          |
|                 | control, and mitigate the   | experience,          |
|                 | impacts of these            | knowledge, skills,   |
|                 | activities, and to assess   | and abilities . . .  |
|                 | performance and implement   | necessary to         |
|                 | corrective actions where    | discharge their      |
|                 | needed"                     | res                  |
|                 |                             | ponsibilities"---DOE |
|                 |                             | P 450.4              |
+-----------------+-----------------------------+----------------------+
| > Emergency     | Procedure Required          | "develop and         |
| > Preparedness  | \[§4.a.(2)\] "procedures .  | implement hazard     |
| > and Response  | . . to manage control, and  | controls"---DOE P    |
|                 | mitigate the impacts of . . | 450.4                |
|                 | . activities \[with         |                      |
|                 | significant environmental   | (also addressed in   |
|                 | impacts\]"                  | other DOE            |
|                 |                             | requirements)        |
+-----------------+-----------------------------+----------------------+
| > Tracking      | Procedure Required          | "feedback on the     |
| > Environmental | \[§4.a.(2)\] "procedures .  | adequacy of controls |
| > Performance   | . . to assess performance . | is gathered"---DOE P |
|                 | . . ."                      | 450.4                |
|                 |                             |                      |
|                 |                             | "data collection,    |
|                 |                             | analysis"---DOE      |
|                 |                             | P 450.5              |
+-----------------+-----------------------------+----------------------+
| > Calibrating   | Procedure Recommended       |                      |
| > Monitoring    | \[§5.d.(15)\]               |                      |
| > and Measuring |                             |                      |
| > Instruments   |                             |                      |
+-----------------+-----------------------------+----------------------+
| > Providing     | Procedure Recommended,      | "open, honest, and   |
| > Internal      | consistent with DOE P 450.1 | responsive           |
| >               | and DOE P 141.2             | communication"---DOE |
|  Communications |                             | P 450.1              |
+-----------------+-----------------------------+----------------------+
| > Responding to | Procedure Recommended,      | "encourage           |
| > External      | consistent with §5.d.(3),   | participation by all |
| > Interested    | as well as DOE P 450.1 and  | interested parties   |
| > Parties       | DOE P 141.2                 | in our activities"   |
|                 |                             |                      |
|                 |                             | "open, honest, and   |
|                 |                             | responsive           |
|                 |                             | communication"---DOE |
|                 |                             | P 450.1              |
|                 |                             |                      |
|                 |                             | "actively seek,      |
|                 |                             | consider, and        |
|                 |                             | respond . . . to the |
|                 |                             | views of . . .       |
|                 |                             | stakeholders" ---DOE |
|                 |                             | P 141.2              |
+-----------------+-----------------------------+----------------------+
| > Providing     | Procedure Recommended,      | "encourage and       |
| > External      | consistent with DOE P 450.1 | promote the sharing  |
| > Communication | and DOE P 141.2             | of ES&H information  |
| > of            |                             | and resources"       |
| > Significant   |                             | ---DOE P 450.1       |
| > Aspects       |                             |                      |
+-----------------+-----------------------------+----------------------+
| > Communicating | Procedure Recommended       | "encourage           |
| > with          |                             | participation by all |
| > Suppliers and |                             | interested parties   |
| > Contractors   |                             | in our activities;"  |
|                 |                             |                      |
|                 |                             | "encourage and       |
|                 |                             | promote the sharing  |
|                 |                             | of ES&H information  |
|                 |                             | and resources"       |
|                 |                             | ---DOE P 450.1       |
+-----------------+-----------------------------+----------------------+
| > Document      | (covered in other DOE       | (implicit in         |
| > Control       | directives)                 | ISMS---covered in    |
|                 |                             | other DOE            |
|                 |                             | directives)          |
+-----------------+-----------------------------+----------------------+
| Records         | (covered in other DOE       | (implicit in         |
| Management      | directives)                 | ISMS---covered in    |
|                 |                             | other DOE            |
|                 |                             | directives)          |
+-----------------+-----------------------------+----------------------+
| >               | Procedure Required          | "provide feedback    |
| Nonconformance, | \[§4.a.(2)\] "procedures to | and continuous       |
| > Corrective    | ... implement corrective    | improvement"---DOE P |
| > and           | actions where needed"       | 450.4                |
| > Preventive    |                             |                      |
| > Action        |                             |                      |
+-----------------+-----------------------------+----------------------+
| > Internal      | Procedure Required          | "line and            |
| > EMS/ISMS and  | \[§4.a.(2)\] "procedures .  | independent          |
| > Compliance    | . . to assess performance   | oversight is         |
| > Status        | and implement corrective    | conducted"---DOE P   |
| > Auditing      | actions where needed"       | 450.4                |
|                 |                             |                      |
|                 |                             | "address . . .       |
|                 |                             | compliance with      |
|                 |                             | applicable           |
|                 |                             | requirements"---DOE  |
|                 |                             | P 450.5              |
+-----------------+-----------------------------+----------------------+
| > Management    | Procedure Required          | DEAR clause; G       |
| > Review        | \[§4.a.(2)\] "includes      | 450.4, Ch IV         |
|                 | procedures to assess        |                      |
|                 | performance"                |                      |
|                 |                             |                      |
|                 | also \[§4.a.(1)\] "EMS . .  |                      |
|                 | . provides for the          |                      |
|                 | systematic . . . evaluation |                      |
|                 | of programs for public      |                      |
|                 | health and environmental    |                      |
|                 | protection, pollution       |                      |
|                 | prevention, and compliance  |                      |
|                 | with applicable             |                      |
|                 | requirements "              |                      |
+-----------------+-----------------------------+----------------------+

1.  Using the Procedure Templates

The example in Table 11 below assumes that following an assessment of a
site's procedures against Table 10 the ISMS/EMS team determines that
there is no suitable procedure for establishing goals, objectives, and
targets consistent with the requirements for an effective ISMS/EMS.

In summary, this procedure should ensure that documented environmental
goals, objectives, and targets, consistent with ES&H policy and P2, are
established and maintained at each relevant function and level within
the organization; that these goals, objectives and targets consider
legal and other requirements and significant environmental aspects
identified in Phase I; and that they consider the technological options,
the views of interested parties, as well as the site's financial,
operational, and business requirements. The following steps summarize
the information that should be reflected in the three sections of the
procedure.

1----Purpose and Scope

The purpose, scope, and definitions in Table 11 require no alteration
unless the ISMS/EMS team decides that changes are needed. For example,
the team may believe that additional introduction on the role of
procedures is necessary or that all the procedures should be listed so
that users understand that this procedure is one of an interlinked set
in the system.

2----Approach

The approach reflected in Table 11 corresponds to the approach described
in Phase I. It may be useful to review the relevant contents of Phase I
at this point. The ISMS/EMS procedure must be created to reflect the
actual procedural tasks to be used onsite. Procedures should make sense
to individuals working onsite (i.e., they should apply to real
operations and activities). One method for ensuring that a procedure can
be followed is to ask someone not involved with this procedure to review
it and then describe how he or she would carry it out.

3----Records

The records section in an ISMS/EMS procedure must be customized to
reflect the actual records that are generated by that procedure. The
records generated must show that the procedure has been carried out and
that the element of the ISMS/EMS in question is implemented effectively.

Table 11. Example of ISMS/EMS Procedure for Determining\
Goals, Objectives, and Targets

![](media/image16.wmf){width="6.473611111111111in"
height="7.811111111111111in"}

Table 11. Example of an ISMS/EMS Procedure (continued)

![](media/image17.wmf){width="6.479861111111111in"
height="7.774305555555555in"}

Table 11. Example of an ISMS/EMS Procedure (continued)

![](media/image18.wmf){width="6.473611111111111in"
height="0.3486111111111111in"}

![](media/image19.wmf){width="6.473611111111111in"
height="5.422916666666667in"}

# APPENDIX C ASSESSMENTS {#appendix-c-assessments .App1}

**CONTENTS**

C.1 Planning the Assessment C-1

C.1.1 Sample Assessment Plan C-2

C.1.2 Assessment Preparation Checklist C-6

C.1.3 Assessment Plan Checklist C-8

C.2 Conducting the Assessment C-9

C.2.1 Assessment Criteria (as a questionnaire) C-10

C.3 Completing the Assessment C-24

C.3.1 Assessment Findings Summary Table C-24

C.3.2 Assessment Summary Report Template C-25

C.3.3 Corrective Action Report Template C-26

1.  Planning the Assessment

Typically, the assessment process should proceed in stages, including
preparation, communication, coordination, execution, documentation, and
closure. The assessment team should develop a plan to conduct the
assessment. A sample assessment plan and an assessment plan checklist
are set forth below.

1.  Sample Assessment Plan

**Sample Assessment Plan with various Fields completed.** The following
Template can be used to plan the ISMS/EMS assessment. Instructions for
completing this template are set forth below.

+-----------------+---+--------------+---+---+-------+-------------------+
| **[Assessment   |   | *            |   |   | **    |                   |
| Plan            |   | *[Assessment |   |   | Asses |                   |
| No.:]{.mark}**  |   | Date         |   |   | sment |                   |
|                 |   | s]{.mark}:** |   |   | team  |                   |
| [1]{.mark}      |   |              |   |   | lead  |                   |
|                 |   | [04/08/03 -- |   |   | er:** |                   |
|                 |   | 04/1         |   |   |       |                   |
|                 |   | 0/03]{.mark} |   |   | *     |                   |
|                 |   |              |   |   | *[Joe |                   |
|                 |   |              |   |   | Ass   |                   |
|                 |   |              |   |   | essor |                   |
|                 |   |              |   |   | ]{.ma |                   |
|                 |   |              |   |   | rk}** |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **A. Assessment |   |              |   |   |       |                   |
| team**          |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Jill           |   |              |   |   |       |                   |
| C               |   |              |   |   |       |                   |
| hecking]{.mark} |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Jennifer       |   |              |   |   |       |                   |
| In              |   |              |   |   |       |                   |
| trusive]{.mark} |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Etc]{.mark}.   |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **B. Assessment |   |              |   |   |       |                   |
| objectives and  |   |              |   |   |       |                   |
| scope**         |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Objective and  |   |              |   |   |       |                   |
| Scope -- Assess |   |              |   |   |       |                   |
| whether an      |   |              |   |   |       |                   |
| ISMS/EMS that   |   |              |   |   |       |                   |
| is fully        |   |              |   |   |       |                   |
| conforming to   |   |              |   |   |       |                   |
| the DOE         |   |              |   |   |       |                   |
| requirements    |   |              |   |   |       |                   |
| has been        |   |              |   |   |       |                   |
| implemented     |   |              |   |   |       |                   |
| facility wide,  |   |              |   |   |       |                   |
| and that this   |   |              |   |   |       |                   |
| ISMS/EMS is     |   |              |   |   |       |                   |
| operating in a  |   |              |   |   |       |                   |
| systematic      |   |              |   |   |       |                   |
| manner and      |   |              |   |   |       |                   |
| achieving its   |   |              |   |   |       |                   |
| desired         |   |              |   |   |       |                   |
| goals.]{.mark}  |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **C. Assessment |   |              |   |   |       |                   |
| Criteria**      |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [See ISMS/EMS   |   |              |   |   |       |                   |
| assessment      |   |              |   |   |       |                   |
| questionnaire   |   |              |   |   |       |                   |
| contained in    |   |              |   |   |       |                   |
| the ISMS/EMS    |   |              |   |   |       |                   |
| procedure       |   |              |   |   |       |                   |
| Section 4, page |   |              |   |   |       |                   |
| 10 of the XYZ   |   |              |   |   |       |                   |
| Plant           |   |              |   |   |       |                   |
| Manual]{.mark}. |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **D.            |   |              |   |   |       |                   |
| Organiza        |   |              |   |   |       |                   |
| tion/functional |   |              |   |   |       |                   |
| units to be     |   |              |   |   |       |                   |
| assessed**      |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| ## [            |   |              |   |   |       |                   |
| All organizatio |   |              |   |   |       |                   |
| nal units]{.mar |   |              |   |   |       |                   |
| k}. {#all-organ |   |              |   |   |       |                   |
| izational-units |   |              |   |   |       |                   |
| . .sub-heading} |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **E. Contact    | * |              | * |   |       |                   |
| person**        | * |              | * |   |       |                   |
|                 | D |              | R |   |       |                   |
|                 | e |              | e |   |       |                   |
|                 | p |              | s |   |       |                   |
|                 | a |              | p |   |       |                   |
|                 | r |              | o |   |       |                   |
|                 | t |              | n |   |       |                   |
|                 | m |              | s |   |       |                   |
|                 | e |              | i |   |       |                   |
|                 | n |              | b |   |       |                   |
|                 | t |              | i |   |       |                   |
|                 | / |              | l |   |       |                   |
|                 | L |              | i |   |       |                   |
|                 | o |              | t |   |       |                   |
|                 | c |              | y |   |       |                   |
|                 | a |              | * |   |       |                   |
|                 | t |              | * |   |       |                   |
|                 | i |              |   |   |       |                   |
|                 | o |              |   |   |       |                   |
|                 | n |              |   |   |       |                   |
|                 | * |              |   |   |       |                   |
|                 | * |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [Jim            | [ |              | [ |   |       |                   |
| O               | L |              | A |   |       |                   |
| perator]{.mark} | a |              | d |   |       |                   |
|                 | b |              | m |   |       |                   |
|                 | o |              | i |   |       |                   |
|                 | r |              | n |   |       |                   |
|                 | a |              | i |   |       |                   |
|                 | t |              | s |   |       |                   |
|                 | o |              | t |   |       |                   |
|                 | r |              | r |   |       |                   |
|                 | i |              | a |   |       |                   |
|                 | e |              | t |   |       |                   |
|                 | s |              | i |   |       |                   |
|                 | ] |              | o |   |       |                   |
|                 | { |              | n |   |       |                   |
|                 | . |              | o |   |       |                   |
|                 | m |              | f |   |       |                   |
|                 | a |              | l |   |       |                   |
|                 | r |              | a |   |       |                   |
|                 | k |              | b |   |       |                   |
|                 | } |              | o |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | t |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | y |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | p |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | t |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | s |   |       |                   |
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|                 |   |              | M |   |       |                   |
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|                 |   |              | E |   |       |                   |
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+-----------------+---+--------------+---+---+-------+-------------------+
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| Pr              | # |              | H |   |       |                   |
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|                 |   |              | h |   |       |                   |
|                 |   |              | R |   |       |                   |
|                 |   |              | C |   |       |                   |
|                 |   |              | R |   |       |                   |
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|                 |   |              | a |   |       |                   |
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|                 |   |              | d |   |       |                   |
|                 |   |              | P |   |       |                   |
|                 |   |              | 2 |   |       |                   |
|                 |   |              | p |   |       |                   |
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|                 |   |              | o |   |       |                   |
|                 |   |              | g |   |       |                   |
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|                 |   |              | m |   |       |                   |
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|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
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|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [Etc]{.mark}    |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **F. Document   |   |              |   |   |       |                   |
| review          |   |              |   |   |       |                   |
| comments**      |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [Reviewed all   |   |              |   |   |       |                   |
| ISMS/EMS        |   |              |   |   |       |                   |
| procedures and  |   |              |   |   |       |                   |
| familiarized    |   |              |   |   |       |                   |
| assessment team |   |              |   |   |       |                   |
| with facility   |   |              |   |   |       |                   |
| ISMS/EMS and    |   |              |   |   |       |                   |
| oper            |   |              |   |   |       |                   |
| ations.]{.mark} |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| ## G. High      |   |              |   |   |       |                   |
| priority elemen |   |              |   |   |       |                   |
| ts  {#g.-high-p |   |              |   |   |       |                   |
| riority-element |   |              |   |   |       |                   |
| s .sub-heading} |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| -   [Hazardous  |   |              |   |   |       |                   |
|     waste       |   |              |   |   |       |                   |
|     satellite   |   |              |   |   |       |                   |
|     storage     |   |              |   |   |       |                   |
|     areas       |   |              |   |   |       |                   |
|     (previous   |   |              |   |   |       |                   |
|     ISMS/EMS    |   |              |   |   |       |                   |
|     assessment  |   |              |   |   |       |                   |
|     identified  |   |              |   |   |       |                   |
|     improvement |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
|   opportunities |   |              |   |   |       |                   |
|     for these   |   |              |   |   |       |                   |
|     storage     |   |              |   |   |       |                   |
|     areas       |   |              |   |   |       |                   |
|     includ      |   |              |   |   |       |                   |
| ing....]{.mark} |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| -   [Office     |   |              |   |   |       |                   |
|     waste       |   |              |   |   |       |                   |
|     recycling   |   |              |   |   |       |                   |
|     pro         |   |              |   |   |       |                   |
| cedures]{.mark} |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| -   [Employee   |   |              |   |   |       |                   |
|     training    |   |              |   |   |       |                   |
|     pro         |   |              |   |   |       |                   |
| cedures]{.mark} |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| ## H. Assessme  |   |              | * |   |       | **Revision**      |
| nt Tasks  {#h.- |   |              | * |   |       |                   |
| assessment-task |   |              | T |   |       |                   |
| s .sub-heading} |   |              | e |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | M |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | b |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | R |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | s |   |       |                   |
|                 |   |              | p |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | s |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | b |   |       |                   |
|                 |   |              | l |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | * |   |       |                   |
|                 |   |              | * |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [- Assessment   |   |              | [ |   |       | [None]{.mark}     |
| Questionnaire   |   |              | J |   |       |                   |
| parts:          |   |              | i |   |       |                   |
| 1--5]{.mark}    |   |              | l |   |       |                   |
|                 |   |              | l |   |       |                   |
| [- Also focus   |   |              | C |   |       |                   |
| on hazardous    |   |              | h |   |       |                   |
| waste           |   |              | e |   |       |                   |
| satellites      |   |              | c |   |       |                   |
| storage         |   |              | k |   |       |                   |
| areas]{.mark}   |   |              | i |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | g |   |       |                   |
|                 |   |              | ] |   |       |                   |
|                 |   |              | { |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [- Assessment   |   |              | [ |   |       | [None]{.mark}     |
| Questionnaire   |   |              | J |   |       |                   |
| parts:          |   |              | o |   |       |                   |
| 6--12]{.mark}   |   |              | h |   |       |                   |
|                 |   |              | n |   |       |                   |
| [Also focus on  |   |              | V |   |       |                   |
| office waste    |   |              | e |   |       |                   |
| recycling       |   |              | r |   |       |                   |
| pro             |   |              | i |   |       |                   |
| cedures]{.mark} |   |              | f |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | ] |   |       |                   |
|                 |   |              | { |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [- Assessment   |   |              | [ |   |       |                   |
| Questionnaire   |   |              | J |   |       |                   |
| parts:          |   |              | e |   |       |                   |
| 13--17]{.mark}  |   |              | n |   |       |                   |
|                 |   |              | n |   |       |                   |
| ## [- Also      |   |              | i |   |       |                   |
|  focus on Emplo |   |              | f |   |       |                   |
| yee training pr |   |              | e |   |       |                   |
| ocedures]{.mark |   |              | r |   |       |                   |
| } {#also-focus- |   |              | I |   |       |                   |
| on-employee-tra |   |              | n |   |       |                   |
| ining-procedure |   |              | t |   |       |                   |
| s .sub-heading} |   |              | r |   |       |                   |
|                 |   |              | u |   |       |                   |
|                 |   |              | s |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | v |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | ] |   |       |                   |
|                 |   |              | { |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **I. Reference  |   |              | * |   |       |                   |
| documents,      |   |              | * |   |       |                   |
| ISMS/EMS        |   |              | R |   |       |                   |
| procedures**    |   |              | e |   |       |                   |
|                 |   |              | v |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | s |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | * |   |       |                   |
|                 |   |              | * |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [XYZ Plant      |   |              | [ |   |       |                   |
| Internal        |   |              | S |   |       |                   |
| Assessment      |   |              | e |   |       |                   |
| Pro             |   |              | c |   |       |                   |
| cedures]{.mark} |   |              | o |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | d |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | v |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | s |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | ( |   |       |                   |
|                 |   |              | 0 |   |       |                   |
|                 |   |              | 3 |   |       |                   |
|                 |   |              | / |   |       |                   |
|                 |   |              | 0 |   |       |                   |
|                 |   |              | 4 |   |       |                   |
|                 |   |              | / |   |       |                   |
|                 |   |              | 0 |   |       |                   |
|                 |   |              | 3 |   |       |                   |
|                 |   |              | ) |   |       |                   |
|                 |   |              | ] |   |       |                   |
|                 |   |              | { |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| [XYZ Plant      |   |              | [ |   |       |                   |
| ISMS/EMS        |   |              | N |   |       |                   |
| Manual]{.mark}  |   |              | / |   |       |                   |
|                 |   |              | A |   |       |                   |
|                 |   |              | ] |   |       |                   |
|                 |   |              | { |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| []{.mark}       |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
|                 |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
|                 |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **J.            |   |              | * |   |       |                   |
| Preassessment   |   |              | * |   |       |                   |
| conference      |   |              | K |   |       |                   |
| schedule**      |   |              | . |   |       |                   |
|                 |   |              | D |   |       |                   |
| *[1 hour        |   |              | a |   |       |                   |
| meeting on      |   |              | i |   |       |                   |
| first morning   |   |              | l |   |       |                   |
| to include      |   |              | y |   |       |                   |
| agenda]{.mark}* |   |              | b |   |       |                   |
|                 |   |              | r |   |       |                   |
| -               |   |              | i |   |       |                   |
|   [Introduction |   |              | e |   |       |                   |
|     to process  |   |              | f |   |       |                   |
|     and         |   |              | i |   |       |                   |
|     assessment  |   |              | n |   |       |                   |
|                 |   |              | g |   |       |                   |
|    team]{.mark} |   |              | s |   |       |                   |
|                 |   |              | s |   |       |                   |
| -               |   |              | c |   |       |                   |
|    [Description |   |              | h |   |       |                   |
|     of          |   |              | e |   |       |                   |
|     assessment  |   |              | d |   |       |                   |
|     s           |   |              | u |   |       |                   |
| chedule]{.mark} |   |              | l |   |       |                   |
|                 |   |              | e |   |       |                   |
| -               |   |              | * |   |       |                   |
|    [Description |   |              | * |   |       |                   |
|     of areas    |   |              |   |   |       |                   |
|     and         |   |              | * |   |       |                   |
|     operations  |   |              | [ |   |       |                   |
|     to be       |   |              | S |   |       |                   |
|                 |   |              | h |   |       |                   |
| visited]{.mark} |   |              | o |   |       |                   |
|                 |   |              | r |   |       |                   |
| -               |   |              | t |   |       |                   |
|   [Confirmation |   |              | s |   |       |                   |
|     of          |   |              | u |   |       |                   |
|     individuals |   |              | m |   |       |                   |
|     inte        |   |              | m |   |       |                   |
| rviewed]{.mark} |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
| -   [Personal   |   |              | y |   |       |                   |
|     Protective  |   |              | b |   |       |                   |
|     Equipment   |   |              | r |   |       |                   |
|     r           |   |              | i |   |       |                   |
| equired]{.mark} |   |              | e |   |       |                   |
|                 |   |              | f |   |       |                   |
| -               |   |              | i |   |       |                   |
|    [Etc]{.mark} |   |              | n |   |       |                   |
|                 |   |              | g |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | t |   |       |                   |
|                 |   |              | t |   |       |                   |
|                 |   |              | h |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | d |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | f |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | c |   |       |                   |
|                 |   |              | h |   |       |                   |
|                 |   |              | d |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | y |   |       |                   |
|                 |   |              | t |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | c |   |       |                   |
|                 |   |              | l |   |       |                   |
|                 |   |              | u |   |       |                   |
|                 |   |              | d |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | g |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | d |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | ] |   |       |                   |
|                 |   |              | { |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
|                 |   |              | * |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **L.            |   |              | * |   |       |                   |
| Postassessment  |   |              | * |   |       |                   |
| conference      |   |              | M |   |       |                   |
| schedule**      |   |              | . |   |       |                   |
|                 |   |              | A |   |       |                   |
| *[1 hour        |   |              | s |   |       |                   |
| meeting on      |   |              | s |   |       |                   |
| first morning   |   |              | e |   |       |                   |
| to include      |   |              | s |   |       |                   |
| agenda]{.mark}* |   |              | s |   |       |                   |
|                 |   |              | m |   |       |                   |
| -   [Summary of |   |              | e |   |       |                   |
|     ass         |   |              | n |   |       |                   |
| essment]{.mark} |   |              | t |   |       |                   |
|                 |   |              | r |   |       |                   |
| ```{=html}      |   |              | e |   |       |                   |
| <!-- -->        |   |              | p |   |       |                   |
| ```             |   |              | o |   |       |                   |
| -               |   |              | r |   |       |                   |
|   [Presentation |   |              | t |   |       |                   |
|     of          |   |              | s |   |       |                   |
|     assessment  |   |              | c |   |       |                   |
|                 |   |              | h |   |       |                   |
|  report]{.mark} |   |              | e |   |       |                   |
|                 |   |              | d |   |       |                   |
| -   [Discussion |   |              | u |   |       |                   |
|     of          |   |              | l |   |       |                   |
|     assessment  |   |              | e |   |       |                   |
|                 |   |              | * |   |       |                   |
|  report]{.mark} |   |              | * |   |       |                   |
|                 |   |              |   |   |       |                   |
| -   [Discussion |   |              | [ |   |       |                   |
|     of          |   |              | A |   |       |                   |
|     corrective  |   |              | s |   |       |                   |
|                 |   |              | s |   |       |                   |
| actions]{.mark} |   |              | e |   |       |                   |
|                 |   |              | s |   |       |                   |
| -   [Discussion |   |              | s |   |       |                   |
|     of          |   |              | m |   |       |                   |
|     assessment  |   |              | e |   |       |                   |
|     report      |   |              | n |   |       |                   |
|     s           |   |              | t |   |       |                   |
| chedule]{.mark} |   |              | s |   |       |                   |
|                 |   |              | u |   |       |                   |
| -               |   |              | m |   |       |                   |
|    [Etc]{.mark} |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | y |   |       |                   |
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|                 |   |              | a |   |       |                   |
|                 |   |              | t |   |       |                   |
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|                 |   |              | f |   |       |                   |
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|                 |   |              | n |   |       |                   |
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|                 |   |              | o |   |       |                   |
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|                 |   |              | f |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | l |   |       |                   |
|                 |   |              | l |   |       |                   |
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|                 |   |              | i |   |       |                   |
|                 |   |              | n |   |       |                   |
|                 |   |              | g |   |       |                   |
|                 |   |              | 1 |   |       |                   |
|                 |   |              | - |   |       |                   |
|                 |   |              | w |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | v |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | w |   |       |                   |
|                 |   |              | p |   |       |                   |
|                 |   |              | e |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | i |   |       |                   |
|                 |   |              | o |   |       |                   |
|                 |   |              | d |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | ] |   |       |                   |
|                 |   |              | { |   |       |                   |
|                 |   |              | . |   |       |                   |
|                 |   |              | m |   |       |                   |
|                 |   |              | a |   |       |                   |
|                 |   |              | r |   |       |                   |
|                 |   |              | k |   |       |                   |
|                 |   |              | } |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **O.            |   |              |   |   |       |                   |
| Communication   |   |              |   |   |       |                   |
| of              |   |              |   |   |       |                   |
| observations/   |   |              |   |   |       |                   |
| findings**      |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Discussion of  |   |              |   |   |       |                   |
| observations    |   |              |   |   |       |                   |
| and findings    |   |              |   |   |       |                   |
| will be         |   |              |   |   |       |                   |
| provided in the |   |              |   |   |       |                   |
| daily           |   |              |   |   |       |                   |
| bri             |   |              |   |   |       |                   |
| efings.]{.mark} |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Summary        |   |              |   |   |       |                   |
| findings will   |   |              |   |   |       |                   |
| be provided on  |   |              |   |   |       |                   |
| closeout        |   |              |   |   |       |                   |
| m               |   |              |   |   |       |                   |
| eeting.]{.mark} |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| []{.mark}       |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| P. **REpORTING  |   |              |   |   |       |                   |
| AND             |   |              |   |   |       |                   |
| dISTRIBUTION    |   |              |   |   |       |                   |
| reQUIREMENTS**  |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Summary and    |   |              |   |   |       |                   |
| final reports   |   |              |   |   |       |                   |
| will be         |   |              |   |   |       |                   |
| distributed to  |   |              |   |   |       |                   |
| senior          |   |              |   |   |       |                   |
| management and  |   |              |   |   |       |                   |
| the ISMS/EMS    |   |              |   |   |       |                   |
| team]{.mark}.   |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [Opportunities  |   |              |   |   |       |                   |
| to make         |   |              |   |   |       |                   |
| programs more   |   |              |   |   |       |                   |
| effective       |   |              |   |   |       |                   |
| and/or          |   |              |   |   |       |                   |
| efficient will  |   |              |   |   |       |                   |
| also be         |   |              |   |   |       |                   |
| reported to     |   |              |   |   |       |                   |
| line management |   |              |   |   |       |                   |
| for their       |   |              |   |   |       |                   |
| consideration,  |   |              |   |   |       |                   |
| DOE P           |   |              |   |   |       |                   |
| 226.1.]{.mark}  |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **N.            |   |              |   |   |       |                   |
| Confidentiality |   |              |   |   |       |                   |
| requirements**  |   |              |   |   |       |                   |
|                 |   |              |   |   |       |                   |
| [All assessment |   |              |   |   |       |                   |
| findings,       |   |              |   |   |       |                   |
| conclusions and |   |              |   |   |       |                   |
| documentation   |   |              |   |   |       |                   |
| are             |   |              |   |   |       |                   |
| confid          |   |              |   |   |       |                   |
| ential.]{.mark} |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
|                 |   |              |   |   |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+
| **Prepared      |   |              |   | * |       |                   |
| by:** [Jill     |   |              |   | * |       |                   |
| C               |   |              |   | R |       |                   |
| hecking]{.mark} |   |              |   | e |       |                   |
|                 |   |              |   | v |       |                   |
|                 |   |              |   | i |       |                   |
|                 |   |              |   | e |       |                   |
|                 |   |              |   | w |       |                   |
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|                 |   |              |   | d |       |                   |
|                 |   |              |   | a |       |                   |
|                 |   |              |   | n |       |                   |
|                 |   |              |   | d |       |                   |
|                 |   |              |   | a |       |                   |
|                 |   |              |   | p |       |                   |
|                 |   |              |   | p |       |                   |
|                 |   |              |   | r |       |                   |
|                 |   |              |   | o |       |                   |
|                 |   |              |   | v |       |                   |
|                 |   |              |   | e |       |                   |
|                 |   |              |   | d |       |                   |
|                 |   |              |   | b |       |                   |
|                 |   |              |   | y |       |                   |
|                 |   |              |   | : |       |                   |
|                 |   |              |   | * |       |                   |
|                 |   |              |   | * |       |                   |
|                 |   |              |   | [ |       |                   |
|                 |   |              |   | J |       |                   |
|                 |   |              |   | o |       |                   |
|                 |   |              |   | e |       |                   |
|                 |   |              |   | A |       |                   |
|                 |   |              |   | s |       |                   |
|                 |   |              |   | s |       |                   |
|                 |   |              |   | e |       |                   |
|                 |   |              |   | s |       |                   |
|                 |   |              |   | s |       |                   |
|                 |   |              |   | o |       |                   |
|                 |   |              |   | r |       |                   |
|                 |   |              |   | ] |       |                   |
|                 |   |              |   | { |       |                   |
|                 |   |              |   | . |       |                   |
|                 |   |              |   | m |       |                   |
|                 |   |              |   | a |       |                   |
|                 |   |              |   | r |       |                   |
|                 |   |              |   | k |       |                   |
|                 |   |              |   | } |       |                   |
|                 |   |              |   |   |       |                   |
|                 |   |              |   | * |       |                   |
|                 |   |              |   | * |       |                   |
|                 |   |              |   | D |       |                   |
|                 |   |              |   | a |       |                   |
|                 |   |              |   | t |       |                   |
|                 |   |              |   | e |       |                   |
|                 |   |              |   | : |       |                   |
|                 |   |              |   | [ |       |                   |
|                 |   |              |   | 0 |       |                   |
|                 |   |              |   | 3 |       |                   |
|                 |   |              |   | / |       |                   |
|                 |   |              |   | 2 |       |                   |
|                 |   |              |   | 2 |       |                   |
|                 |   |              |   | / |       |                   |
|                 |   |              |   | 0 |       |                   |
|                 |   |              |   | 3 |       |                   |
|                 |   |              |   | ] |       |                   |
|                 |   |              |   | { |       |                   |
|                 |   |              |   | . |       |                   |
|                 |   |              |   | m |       |                   |
|                 |   |              |   | a |       |                   |
|                 |   |              |   | r |       |                   |
|                 |   |              |   | k |       |                   |
|                 |   |              |   | } |       |                   |
|                 |   |              |   | * |       |                   |
|                 |   |              |   | * |       |                   |
+-----------------+---+--------------+---+---+-------+-------------------+

## Instructions for completing the assessment plan template {#instructions-for-completing-the-assessment-plan-template .sub1}

1.  At the top of the plan enter the plan number, the plan date, and the
    assessment team leader.

2.  Field A contains a list of the assessment team members. Team members
    should---

-   be adequately qualified and experienced,

-   be impartial and objective,

-   be ethical,

-   provide fair presentation of the facts, and

-   show professionalism.

3.  Enter assessment objectives and scope in field B. Objectives may
    cover any areas that the team or organization wishes but should at
    minimum include---

-   assessment of the ISMS/EMS capability to maintain compliance,

-   assessment of the ISMS/EMS operational effectiveness and
    systemization, and

-   assessment of the completeness of implementation.

The scope of the assessment should cover all locations and individuals
covered by the ISMS/EMS. This includes all members of the organization,
with special attention to employees with specific roles such as: Senior
management, the ISMS/EMS coordinator, the ISMS/EMS team, and any
employees with specific responsibilities under the ISMS/EMS.

4.  In field C, enter a reference to the ISMS/EMS assessment criteria
    against which the assessment will evaluate the organization.

For example, if your organization is basing part of its assessment
criteria on the questionnaire discussed in section C.2.1 of this
appendix, it might reference the location of this criteria.

5.  In field D, identify the organizational units to be assessed. This
    could include all the organizational units.

6.  In field E, enter the names of all the individuals with whom you
    will be speaking during the assessment as well as the department
    they are in and the responsibilities or roles they perform

7.  In field F, enter the results of a review of the organization's
    documentation including---

-   all documentation related to the ISMS/EMS,

-   previous assessment reports and findings, and

-   records relating to the ISMS/EMS.

8.  In field G, identify those areas of the ISMS/EMS that are priorities
    and on which the onsite portion of assessment should focus. These
    may include---

-   previous assessment findings;

-   areas not well covered in previous assessments;

-   new organizational activities, products, and services; and

-   areas of specific mission or environmental importance.

The team members will need to familiarize themselves with this
information in preparation for the assessment.

9.  In field H, list the assessment team members responsible for certain
    portions of the ISMS/EMS assessment questionnaire (section C.2.1 of
    this appendix). In addition, use this field to designate priority
    areas to specific team members to ensure that the assessment covers
    all criteria questionnaire items.

10. In field I, enter references to those documents that the assessment
    team will use for the assessment. In particular, note those elements
    of the organization's assessment procedure to be used in the
    assessment.

11. In fields J, K, L, and M, enter the schedule for the preassessment
    conference, daily briefings, the postassessment conference, and the
    assessment reports.

12. In fields N, O, and P, list the methods the team will use to
    communicate observations and findings during the assessment,
    reporting and distributing requirements, and any confidentiality
    requirements.

13. Finally, enter the name of the individual who completed the plan,
    the individual who reviewed and approved the plan, and the date.

14. While working through the assessment plan, complete the assessment
    plan checklist (see below) to ensure all necessary planning tasks
    are completed prior to the assessment.

    1.  Assessment Preparation Checklist

This checklist can be used to make sure that the assessment team is
prepared for conducting the assessment.

+---------------------------------+-----------+-----------+------------+
| INTERNAL ASSESSMENT PREPARATION |           |           |            |
| CHECKLIST                       |           |           |            |
+---------------------------------+-----------+-----------+------------+
| ## Department/Site              |           |           |            |
|  to be assessed: {#departmentsi |           |           |            |
| te-to-be-assessed .sub-heading} |           |           |            |
+---------------------------------+-----------+-----------+------------+
| **Assessment Date:**            |           |           |            |
+---------------------------------+-----------+-----------+------------+
|                                 |           |           |            |
+---------------------------------+-----------+-----------+------------+
| **Assessment Objectives, Scope, |           |           |            |
| and Criteria**                  |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Do assessment objectives test   | Yes       | No        |            |
| capability to maintain          |           |           |            |
| compliance:                     |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Does the assessment scope       | A         | Units     | Time       |
| assess boundaries, activities,  | ctivities |           |            |
| units or time period:           |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Does the assessment criteria    | Program   | Standards | Contract\  |
| include programs, standards,    |           |           | Re         |
| contract requirements:          |           |           | quirements |
+---------------------------------+-----------+-----------+------------+
| Assessment Feasibility          |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Have the team assured that      | Yes       | No        |            |
| necessary information is        |           |           |            |
| available:                      |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Has the availability of         | Yes       | No        |            |
| assessment team members been    |           |           |            |
| sought and gained:              |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Makeup of Assessment Team       |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Has the objectivity of the      | C         | Ensured   |            |
| assessment team been considered | onsidered |           |            |
| and ensured:                    |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Has the competence of the       | C         | Ensured   |            |
| assessment team been considered | onsidered |           |            |
| and ensured:                    |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Has the appropriateness of      | C         | Ensured   |            |
| assessment team been considered | onsidered |           |            |
| and ensured:                    |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Contact the Assessed Unit       |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Has the assessment team         | Yes       | No        |            |
| established a dialogue with the |           |           |            |
| assessed unit:                  |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Have all necessary documents    | I         | Requested | Are        |
| been identified, requested to   | dentified |           | available  |
| be made available and are       |           |           |            |
| available:                      |           |           |            |
+---------------------------------+-----------+-----------+------------+
| What dialogue/interaction has   |           |           |            |
| taken place:                    |           |           |            |
+---------------------------------+-----------+-----------+------------+
|                                 |           |           |            |
+---------------------------------+-----------+-----------+------------+
|                                 |           |           |            |
+---------------------------------+-----------+-----------+------------+
| Have the logistics been         | Yes       | No        |            |
| determined:                     |           |           |            |
+---------------------------------+-----------+-----------+------------+

+---------------------+-----------+--------+---+----+-----+---------+---+
| Document Review     |           |        |   |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have ambiguities    |           | Yes    |   | No |     |         |   |
| been clarified:     |           |        |   |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have all necessary  |           | Iden   |   | R  |     | Are     |   |
| records and         |           | tified |   | eq |     | av      |   |
| documents been      |           |        |   | ue |     | ailable |   |
| identified,         |           |        |   | st |     |         |   |
| requested to be     |           |        |   | ed |     |         |   |
| made available and  |           |        |   |    |     |         |   |
| are available:      |           |        |   |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have previous       |           | Iden   |   | R  |     | Are     |   |
| assessments been    |           | tified |   | eq |     | av      |   |
| requested to be     |           |        |   | ue |     | ailable |   |
| made available and  |           |        |   | st |     |         |   |
| are available:      |           |        |   | ed |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have prior          |           | Iden   |   | R  |     | Are     |   |
| nonconformances     |           | tified |   | eq |     | av      |   |
| requested to be     |           |        |   | ue |     | ailable |   |
| made available and  |           |        |   | st |     |         |   |
| are available:      |           |        |   | ed |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have                |           | Iden   |   | R  |     | Are     |   |
| co                  |           | tified |   | eq |     | av      |   |
| rrective/preventive |           |        |   | ue |     | ailable |   |
| actions been        |           |        |   | st |     |         |   |
| requested to be     |           |        |   | ed |     |         |   |
| made available and  |           |        |   |    |     |         |   |
| are available:      |           |        |   |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have organization   |           | Iden   |   | R  |     | Are     |   |
| charts and          |           | tified |   | eq |     | av      |   |
| procedures been     |           |        |   | ue |     | ailable |   |
| requested to be     |           |        |   | st |     |         |   |
| made available and  |           |        |   | ed |     |         |   |
| are available:      |           |        |   |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have monitoring and |           | Iden   |   | R  |     | Are     |   |
| measurement records |           | tified |   | eq |     | av      |   |
| been requested to   |           |        |   | ue |     | ailable |   |
| be made available   |           |        |   | st |     |         |   |
| and are available:  |           |        |   | ed |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have compliance     |           | Iden   |   | R  |     | Are     |   |
| status records been |           | tified |   | eq |     | av      |   |
| requested to be     |           |        |   | ue |     | ailable |   |
| made available and  |           |        |   | st |     |         |   |
| are available:      |           |        |   | ed |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have permits been   |           | Iden   |   | R  |     | Are     |   |
| requested to be     |           | tified |   | eq |     | av      |   |
| made available and  |           |        |   | ue |     | ailable |   |
| are available:      |           |        |   | st |     |         |   |
|                     |           |        |   | ed |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| Have management     |           | Iden   |   | R  |     | Are     |   |
| review reports been |           | tified |   | eq |     | av      |   |
| requested to be     |           |        |   | ue |     | ailable |   |
| made available and  |           |        |   | st |     |         |   |
| are available:      |           |        |   | ed |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| ## Assessed         |           | Yes    |   | #  |     |         |   |
|  Unit contacted:  { |           |        |   | #  |     |         |   |
| #assessed-unit-cont |           |        |   | Da |     |         |   |
| acted .sub-heading} |           |        |   | te |     |         |   |
|                     |           |        |   | :  |     |         |   |
|                     |           |        |   | {# |     |         |   |
|                     |           |        |   | da |     |         |   |
|                     |           |        |   | te |     |         |   |
|                     |           |        |   |  . |     |         |   |
|                     |           |        |   | su |     |         |   |
|                     |           |        |   | b- |     |         |   |
|                     |           |        |   | he |     |         |   |
|                     |           |        |   | ad |     |         |   |
|                     |           |        |   | in |     |         |   |
|                     |           |        |   | g} |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| **Assessors         |           | Yes    |   | *  |     |         |   |
| notified:**         |           |        |   | *D |     |         |   |
|                     |           |        |   | at |     |         |   |
|                     |           |        |   | e: |     |         |   |
|                     |           |        |   | ** |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| **Set opening       |           |        |   |    |     |         |   |
| meeting date:**     |           |        |   |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
| **Assessors         |           |        | * |    |     |         |   |
| Names:**            |           |        | * |    |     |         |   |
|                     |           |        | D |    |     |         |   |
|                     |           |        | a |    |     |         |   |
|                     |           |        | t |    |     |         |   |
|                     |           |        | e |    |     |         |   |
|                     |           |        | : |    |     |         |   |
|                     |           |        | * |    |     |         |   |
|                     |           |        | * |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+
|                     |           |        |   |    |     |         |   |
+---------------------+-----------+--------+---+----+-----+---------+---+

2.  Assessment Plan Checklist

  --------------------------- ------------------------- ----------------- --------------- -------------------- --------------------
  **[Assessment Plan                                    **[Assessment                                          
  No.]{.mark}**                                         Dates]{.mark}**                                        

                                                                                                               

  **A. Assessment objectives                                                                                   
  and scope**                                                                                                  

  **B. Assessment Criteria**                                                                                   

  **C.                                                                                                         
  Organizational/functional                                                                                    
  units to be assessed**                                                                                       

  **D. Contact person**       **Department/Location**                                     **Responsibility**   

                                                                                                               

                                                                                                               

                                                                                                               

                                                                                                               

                                                                                                               

  **E. High priority                                                                                           
  elements**                                                                                                   

  **F. Assessment procedures                                                                                   **Revision**
  Title**                                                                                                      

                                                                                                               

                                                                                                               

                                                                                                               

                                                                                                               

                                                                                                               

                                                                                                               

  **G. Communication of                                                                                        
  observations/ findings                                                                                       
  during the assessments**                                                                                     

  **H. Reference documents**                                              **Revision**                         

                                                                                                               

                                                                                                               

                                                                                                               

                                                                                                               

                                                                                                               

  **I. Time/duration of                                                                                        
  assessments**                                                                                                

  **J. Date**                                                             **Locations**                        

  **L. Assessment Team                                                                                         
  Members**                                                                                                    

  **M. Preassessment                                                      **N. Daily                           
  conference schedule**                                                   briefings                            
                                                                          schedule**                           

  **O. Postassessment                                                     **P. Assessment                      
  conference schedule**                                                   report                               
                                                                          schedule**                           

  **Q. Confidentiality                                                                                         
  requirements**                                                                                               

  **R. Reporting and                                                                                           
  distribution requirements**                                                                                  

                                                                                                               

  **Prepared by:**                                                        **Reviewed and                       
                                                                          approved by:**                       
  --------------------------- ------------------------- ----------------- --------------- -------------------- --------------------

1.  Conducting the Assessment

Once all the planning activities are completed, the assessment team
should be ready to conduct the assessment. The team does the assessment
primarily through the analyses of documentation, and by observing and
interviewing employees. One of the stages in the assessment process
includes assessing observations against criteria. The criteria below are
an example of assessment criteria used by a DOE facility. Members of the
assessment team can use this questionnaire to determine (1) root causes
of system failures, (2) areas that conform and have best practices, and
(3) areas where further improvements can be made.

1.  Assessment Criteria (as a questionnaire)

+--------------------------------------+----+------+---------+--------+
| **Questions to address system        | *  | **   | *       | **Com  |
| requirements and root causes**       | *F | Best | *Opport | ment** |
|                                      | in | pr   | unities |        |
|                                      | di | acti | to      |        |
|                                      | ng | ce** | im      |        |
|                                      | ** |      | prove** |        |
+======================================+====+======+=========+========+
| ## 1.                                |    |      |         |        |
|  Questions to determine implementati |    |      |         |        |
| on and effectiveness of the environm |    |      |         |        |
| ental policy {#questions-to-determin |    |      |         |        |
| e-implementation-and-effectiveness-o |    |      |         |        |
| f-the-environmental-policy .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| *System Requirements:*               |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Does the organization have an        |    |      |         |        |
| environmental policy?                |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Does the policy reflect the      |    |      |         |        |
|     organization's values?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the policy drive the        |    |      |         |        |
|     setting of Environmental         |    |      |         |        |
|     objectives and targets?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Does the policy include a        |    |      |         |        |
|     commitment to the prevention of  |    |      |         |        |
|     pollution?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Does the policy include          |    |      |         |        |
|     commitments to continual         |    |      |         |        |
|     improvement and compliance to    |    |      |         |        |
|     relevant laws and other          |    |      |         |        |
|     requirements to which the        |    |      |         |        |
|     organization subscribes?         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Is the policy appropriate to the |    |      |         |        |
|     nature, scale and environmental  |    |      |         |        |
|     impacts of the organization's    |    |      |         |        |
|     activities, products or          |    |      |         |        |
|     services?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Is the policy communicated to    |    |      |         |        |
|     all employees and made available |    |      |         |        |
|     to the public?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Is it clear that the policy has  |    |      |         |        |
|     senior management's endorsement  |    |      |         |        |
|     and commitment?                  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 8.  Does the policy provide a        |    |      |         |        |
|     framework for setting and        |    |      |         |        |
|     reviewing environmental          |    |      |         |        |
|     objectives and targets at all    |    |      |         |        |
|     levels within the organization?  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 9\. Was top management involved in   |    |      |         |        |
| crafting the policy?                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 10\. Are there any obvious           |    |      |         |        |
| inconsistencies between the policy   |    |      |         |        |
| commitments and organizational       |    |      |         |        |
| practices?                           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 11\. Do employees believe that       |    |      |         |        |
| management is sincere?               |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 12\. Does management believe that    |    |      |         |        |
| environmental management will        |    |      |         |        |
| improve the quality and success of   |    |      |         |        |
| this organization?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 13\. Is there evidence that          |    |      |         |        |
| sufficient resources will be         |    |      |         |        |
| allocated to the ISMS/EMS            |    |      |         |        |
| implementation over a sustained      |    |      |         |        |
| period?                              |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 2. Q                              |    |      |         | ##  {# |
| uestions to determine implementation |    |      |         | sectio |
|  and effectiveness of the Environmen |    |      |         | n-11 . |
| tal Aspects {#questions-to-determine |    |      |         | sub-he |
| -implementation-and-effectiveness-of |    |      |         | ading} |
| -the-environmental-aspects .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Has a procedure to identify the  |    |      |         |        |
|     significant environmental        |    |      |         |        |
|     aspects of operations, products, |    |      |         |        |
|     and services been established    |    |      |         |        |
|     and implemented?                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does this procedure include      |    |      |         |        |
|     determining which aspects the    |    |      |         |        |
|     organization can be expected to  |    |      |         |        |
|     have influence over?             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Has the organization developed   |    |      |         |        |
|     criteria for identifying those   |    |      |         |        |
|     aspects which have or can have   |    |      |         |        |
|     significant impacts?             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Have all aspects which can have  |    |      |         |        |
|     significant impacts been         |    |      |         |        |
|     designated as significant        |    |      |         |        |
|     aspects?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Have all aspects with regulatory |    |      |         |        |
|     requirements been designated as  |    |      |         |        |
|     significant aspects?             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Is the procedure to identify     |    |      |         |        |
|     significant environmental        |    |      |         |        |
|     aspects exercised periodically   |    |      |         |        |
|     to maintain currency?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Is the procedure generally       |    |      |         |        |
|     sufficient given the nature,     |    |      |         |        |
|     scale and potential              |    |      |         |        |
|     environmental impacts of this    |    |      |         |        |
|     organization?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Does the procedure provide for   |    |      |         |        |
|     the evaluation of all inputs,    |    |      |         |        |
|     processes, operations, products  |    |      |         |        |
|     and services? Has this been      |    |      |         |        |
|     done?                            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Are the persons doing the        |    |      |         |        |
|     evaluation sufficiently versed   |    |      |         |        |
|     in environmental matters to      |    |      |         |        |
|     reliably identify environmental  |    |      |         |        |
|     aspects?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is there commitment to execute   |    |      |         |        |
|     the procedure frequently so as   |    |      |         |        |
|     to capture any new aspects?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Were the products or services    |    |      |         |        |
|     from external suppliers          |    |      |         |        |
|     sufficiently evaluated for       |    |      |         |        |
|     environmental aspects?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Does the significance criteria   |    |      |         |        |
|     truly reflect the values and     |    |      |         |        |
|     priorities of the organization?  |    |      |         |        |
|     Has there been a thoughtful      |    |      |         |        |
|     consideration of the             |    |      |         |        |
|     consequences?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Are business exposures           |    |      |         |        |
|     adequately represented in the    |    |      |         |        |
|     significance criteria?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 3. Questions to de                |    |      |         | ##     |
| termine implementation and effective |    |      |         |   {#se |
| ness of the Legal and Other Requirem |    |      |         | ction- |
| ents {#questions-to-determine-implem |    |      |         | 12 .Ta |
| entation-and-effectiveness-of-the-le |    |      |         | ble-q} |
| gal-and-other-requirements .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Has a procedure to identify and  |    |      |         |        |
|     provide access to applicable     |    |      |         |        |
|     laws and regulation, and other   |    |      |         |        |
|     environmental requirements to    |    |      |         |        |
|     which the organization           |    |      |         |        |
|     subscribes been established and  |    |      |         |        |
|     implemented?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the procedure identify      |    |      |         |        |
|     environmental legal requirements |    |      |         |        |
|     for activities, products and     |    |      |         |        |
|     services?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Does the procedure address       |    |      |         |        |
|     applicable international,        |    |      |         |        |
|     national, state, provincial,     |    |      |         |        |
|     local, or contractual            |    |      |         |        |
|     requirements?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Is the flow of information on    |    |      |         |        |
|     legal requirements reliable,     |    |      |         |        |
|     competent, and unobstructed?     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Have the legal and other         |    |      |         |        |
|     requirements been translated     |    |      |         |        |
|     into nontechnical language and   |    |      |         |        |
|     brought to the individuals that  |    |      |         |        |
|     will have primary responsibility |    |      |         |        |
|     for compliance? (This is the     |    |      |         |        |
|     meaning of "provide access" in   |    |      |         |        |
|     the standard.)                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Does the procedure ensure that   |    |      |         |        |
|     when new aspects arise they will |    |      |         |        |
|     be reviewed for any regulatory   |    |      |         |        |
|     requirements?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Have all identified aspects been |    |      |         |        |
|     reviewed by a legally competent  |    |      |         |        |
|     individual to ascertain the      |    |      |         |        |
|     existence of any regulatory      |    |      |         |        |
|     requirements?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Are qualified individuals that   |    |      |         |        |
|     can determine the applicability  |    |      |         |        |
|     of regulations to specific       |    |      |         |        |
|     configurations of environmental  |    |      |         |        |
|     aspects accessible? Are they     |    |      |         |        |
|     engaged in the process?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Has the need for redundant       |    |      |         |        |
|     sources of regulatory            |    |      |         |        |
|     information been considered? If  |    |      |         |        |
|     such a need is perceived, are    |    |      |         |        |
|     there redundant sources?         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Do line personnel appreciate, in |    |      |         |        |
|     layman's terms, the legal        |    |      |         |        |
|     requirements that apply to their |    |      |         |        |
|     specific duties? Is this tested  |    |      |         |        |
|     from time to time?               |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Is there a general awareness     |    |      |         |        |
|     among employees that legal       |    |      |         |        |
|     duties attach to certain         |    |      |         |        |
|     environmental responsibilities?  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 4. Que                            |    |      |         |        |
| stions to determine implementation a |    |      |         |        |
| nd effectiveness of the Objectives a |    |      |         |        |
| nd Targets {#questions-to-determine- |    |      |         |        |
| implementation-and-effectiveness-of- |    |      |         |        |
| the-objectives-and-targets .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are objectives and targets based |    |      |         |        |
|     on the environmental policy,     |    |      |         |        |
|     take into account significant    |    |      |         |        |
|     environmental aspects, legal and |    |      |         |        |
|     other requirements and the views |    |      |         |        |
|     of interested parties?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Has the organization developed a |    |      |         |        |
|     method or criteria for           |    |      |         |        |
|     determining who its "interested  |    |      |         |        |
|     parties" are for the purposes of |    |      |         |        |
|     the ISMS/EMS?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Does the organization keep the   |    |      |         |        |
|     views of interested parties?     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are there objectives and targets |    |      |         |        |
|     for all significant              |    |      |         |        |
|     environmental aspects? (Even     |    |      |         |        |
|     those that have already achieved |    |      |         |        |
|     their objective?)                |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Is the objective for aspects     |    |      |         |        |
|     with regulatory requirements to  |    |      |         |        |
|     reach compliance?                |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  In setting objectives and        |    |      |         |        |
|     targets, were technological      |    |      |         |        |
|     options and its financial,       |    |      |         |        |
|     operational and business         |    |      |         |        |
|     requirements considered?         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Do objectives and targets        |    |      |         |        |
|     contain a commitment to P2?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 8.  Have the objectives and targets  |    |      |         |        |
|     been distributed to each         |    |      |         |        |
|     relevant function and level      |    |      |         |        |
|     within the organization?         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 9.  Are the individuals that need to |    |      |         |        |
|     achieve objectives and targets   |    |      |         |        |
|     aware of what is expected of     |    |      |         |        |
|     them?                            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Do the objectives and targets    |    |      |         |        |
|     reflect the vision and           |    |      |         |        |
|     aspirations communicated by the  |    |      |         |        |
|     policy statement?                |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Has top management agreed with   |    |      |         |        |
|     the scope and reach of the       |    |      |         |        |
|     objectives and targets?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Will achieving the objectives    |    |      |         |        |
|     and targets result in the        |    |      |         |        |
|     advantages and benefits          |    |      |         |        |
|     envisioned when the ISMS/EMS was |    |      |         |        |
|     conceived?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Does management keep track of    |    |      |         |        |
|     progress towards achieving the   |    |      |         |        |
|     objectives and targets?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Have indicators of progress been |    |      |         |        |
|     chosen with care to allow        |    |      |         |        |
|     monitoring and measurement with  |    |      |         |        |
|     relative ease?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Is responsibility for keeping    |    |      |         |        |
|     track of objectives and targets, |    |      |         |        |
|     clearly designated, and is       |    |      |         |        |
|     oversight sufficient to ensure   |    |      |         |        |
|     this occurs?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Is there a general awareness     |    |      |         |        |
|     among the employees of the       |    |      |         |        |
|     objectives and targets of the    |    |      |         |        |
|     EMS?                             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 5. Questions to determine im      |    |      |         |        |
| plementation and effectiveness of th |    |      |         |        |
| e Environmental Management Programs  |    |      |         |        |
| {#questions-to-determine-implementat |    |      |         |        |
| ion-and-effectiveness-of-the-environ |    |      |         |        |
| mental-management-programs .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are there Environmental          |    |      |         |        |
|     Management Programs (EMPs) for   |    |      |         |        |
|     achieving all objectives and     |    |      |         |        |
|     targets?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Do EMPs designate                |    |      |         |        |
|     responsibilities for achieving   |    |      |         |        |
|     the objectives and targets at    |    |      |         |        |
|     each relevant function and level |    |      |         |        |
|     of the organization?             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Do EMPs include the means and    |    |      |         |        |
|     timeframe for achievement?       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Have the relevant programs been  |    |      |         |        |
|     revised to address new or        |    |      |         |        |
|     modified activities, products or |    |      |         |        |
|     services?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Do the management programs       |    |      |         |        |
|     incorporate these elements of    |    |      |         |        |
|     the ISMS/EMS:                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Objectives and targets           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Structure and responsibility     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Training, awareness and          |    |      |         |        |
|     competence                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Records, identification and      |    |      |         |        |
|     retention                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Operational control              |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Monitoring and measurement       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Performance indicators           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Documents to be used             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Resources and timeframes         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are there programs to address    |    |      |         |        |
|     all significant aspects in all   |    |      |         |        |
|     activities, operations, products |    |      |         |        |
|     and services in which they       |    |      |         |        |
|     exist?                           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Is there sufficient detail in    |    |      |         |        |
|     the program to cover all         |    |      |         |        |
|     instances of each significant    |    |      |         |        |
|     aspect?                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is someone in the organization   |    |      |         |        |
|     designated to be responsible to  |    |      |         |        |
|     oversee each program? Are        |    |      |         |        |
|     responsibilities for the various |    |      |         |        |
|     parts of each program clearly    |    |      |         |        |
|     designated?                      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are persons with                 |    |      |         |        |
|     responsibilities for various     |    |      |         |        |
|     parts of each program aware and  |    |      |         |        |
|     committed to their roles?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Are the resources allocated to   |    |      |         |        |
|     each program sufficient to make  |    |      |         |        |
|     the program successful?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Do designated individuals have   |    |      |         |        |
|     enough time left from their      |    |      |         |        |
|     other duties to allocate to the  |    |      |         |        |
|     programs?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 6.                                |    |      |         |        |
|  Questions to determine implementati |    |      |         |        |
| on and effectiveness of the Operatio |    |      |         |        |
| nal Controls {#questions-to-determin |    |      |         |        |
| e-implementation-and-effectiveness-o |    |      |         |        |
| f-the-operational-controls .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Have documented operational      |    |      |         |        |
|     controls for activities          |    |      |         |        |
|     associated with significant      |    |      |         |        |
|     environmental aspects been       |    |      |         |        |
|     developed and implemented?       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the organization have       |    |      |         |        |
|     procedures that stipulate the    |    |      |         |        |
|     operating criteria and           |    |      |         |        |
|     operational controls for         |    |      |         |        |
|     identified operations and        |    |      |         |        |
|     activities?                      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Does the organization have       |    |      |         |        |
|     procedures to cover control      |    |      |         |        |
|     situations that deviate from the |    |      |         |        |
|     environmental policy and         |    |      |         |        |
|     objectives and targets?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Has the organization assigned    |    |      |         |        |
|     responsibility for reviewing,    |    |      |         |        |
|     maintaining, and updating        |    |      |         |        |
|     operational controls and         |    |      |         |        |
|     procedures?                      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Have controls and procedures     |    |      |         |        |
|     been communicated to suppliers   |    |      |         |        |
|     and contractors relative to any  |    |      |         |        |
|     significant environmental        |    |      |         |        |
|     aspects of goods and services    |    |      |         |        |
|     used by the organization?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Does the organization have a     |    |      |         |        |
|     procedure to identify the        |    |      |         |        |
|     significant environmental        |    |      |         |        |
|     aspects of externally provided   |    |      |         |        |
|     goods and services?              |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Have individuals responsible for |    |      |         |        |
|     operational controls been        |    |      |         |        |
|     notified and qualified for those |    |      |         |        |
|     controls?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 8.  Have operators been made aware   |    |      |         |        |
|     where operational controls are   |    |      |         |        |
|     necessary to achieve and         |    |      |         |        |
|     maintain compliance to           |    |      |         |        |
|     regulatory requirements?         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Have operational controls been   |    |      |         |        |
|     carefully considered and crafted |    |      |         |        |
|     for each activity, product or    |    |      |         |        |
|     service that is associated with  |    |      |         |        |
|     a significant aspect? (Has this  |    |      |         |        |
|     really happened and did the      |    |      |         |        |
|     analysis include specifying      |    |      |         |        |
|     operating criteria, maintenance  |    |      |         |        |
|     and backup controls?)            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Are the people on whom the       |    |      |         |        |
|     organization relies for manning  |    |      |         |        |
|     the operational controls aware,  |    |      |         |        |
|     committed, competent and         |    |      |         |        |
|     resourced to do their jobs?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is the monitoring of operational |    |      |         |        |
|     controls frequent enough to      |    |      |         |        |
|     allow recovery in case of        |    |      |         |        |
|     malfunction or error?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are operational controls         |    |      |         |        |
|     assessed for their adequacy once |    |      |         |        |
|     they've been in place for a      |    |      |         |        |
|     while?                           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 7. Questions to de                |    |      |         |        |
| termine implementation and effective |    |      |         |        |
| ness of the Structure and Responsibi |    |      |         |        |
| lity {#questions-to-determine-implem |    |      |         |        |
| entation-and-effectiveness-of-the-st |    |      |         |        |
| ructure-and-responsibility .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Have defined roles,              |    |      |         |        |
|     responsibilities and authorities |    |      |         |        |
|     been established and             |    |      |         |        |
|     communicated to the appropriate  |    |      |         |        |
|     employees?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Have sufficient financial,       |    |      |         |        |
|     technical and personnel          |    |      |         |        |
|     resources been made available to |    |      |         |        |
|     implement the ISMS/EMS?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Has a management representative  |    |      |         |        |
|     been appointed by senior         |    |      |         |        |
|     management to oversee the        |    |      |         |        |
|     ISMS/EMS and to report on its    |    |      |         |        |
|     performance and progress?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are roles, responsibilities and  |    |      |         |        |
|     authorities appropriately        |    |      |         |        |
|     specified within the             |    |      |         |        |
|     environmental management         |    |      |         |        |
|     programs?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
|                                      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Have the employees shown that    |    |      |         |        |
|     they understand their            |    |      |         |        |
|     responsibilities and will        |    |      |         |        |
|     actually fulfill them?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Were the employees given the     |    |      |         |        |
|     opportunity to structure the     |    |      |         |        |
|     procedures they will follow to   |    |      |         |        |
|     execute their responsibilities?  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  When an employee leaves and      |    |      |         |        |
|     another takes his/her place, is  |    |      |         |        |
|     there a process for reassigning  |    |      |         |        |
|     responsibilities and getting     |    |      |         |        |
|     understanding, competence and    |    |      |         |        |
|     commitment from the new          |    |      |         |        |
|     employee?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Is the understanding and         |    |      |         |        |
|     commitment refreshed frequently  |    |      |         |        |
|     enough so it is not forgotten or |    |      |         |        |
|     neglected?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Are responsibilities fairly      |    |      |         |        |
|     distributed so as not to         |    |      |         |        |
|     overburden some individuals?     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Are the assigned                 |    |      |         |        |
|     responsibilities logical and a   |    |      |         |        |
|     natural fit in the employee's    |    |      |         |        |
|     normal duties?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 8. Questions to deter             |    |      |         |        |
| mine implementation and effectivenes |    |      |         |        |
| s of Training, Awareness and Compete |    |      |         |        |
| nce {#questions-to-determine-impleme |    |      |         |        |
| ntation-and-effectiveness-of-trainin |    |      |         |        |
| g-awareness-and-competence .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Has the organization identified  |    |      |         |        |
|     and evaluated training needs for |    |      |         |        |
|     all personnel and contractors,   |    |      |         |        |
|     where appropriate, whose         |    |      |         |        |
|     functions may create a           |    |      |         |        |
|     significant impact on the        |    |      |         |        |
|     environment?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Has the organization identified  |    |      |         |        |
|     training needs for providing     |    |      |         |        |
|     general awareness to all         |    |      |         |        |
|     employees and managers at each   |    |      |         |        |
|     relevant function and level?     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Does training emphasize the      |    |      |         |        |
|     importance of compliance with    |    |      |         |        |
|     all applicable laws and          |    |      |         |        |
|     regulations, conformance with    |    |      |         |        |
|     the organization's environmental |    |      |         |        |
|     policy and with the requirements |    |      |         |        |
|     of the ISMS/EMS?                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Does training emphasize the      |    |      |         |        |
|     significant environmental        |    |      |         |        |
|     impacts, actual or potential, of |    |      |         |        |
|     work activities?                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Does training emphasize the      |    |      |         |        |
|     environmental benefits of        |    |      |         |        |
|     improved personal performance    |    |      |         |        |
|     relative to environmental        |    |      |         |        |
|     aspects?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Does training emphasize the      |    |      |         |        |
|     roles and responsibilities of    |    |      |         |        |
|     employees and onsite contractors |    |      |         |        |
|     in achieving conformity with the |    |      |         |        |
|     environmental policy and         |    |      |         |        |
|     procedures?                      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Does training emphasize the      |    |      |         |        |
|     potential consequences of        |    |      |         |        |
|     departure from specified         |    |      |         |        |
|     operating procedures?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 8.  Are all employees whose work can |    |      |         |        |
|     cause significant environmental  |    |      |         |        |
|     impacts competent by training,   |    |      |         |        |
|     experience, or education?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 9.  Has a determination of           |    |      |         |        |
|     competence for such employees    |    |      |         |        |
|     been made and recorded?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 10. Does the employee know that he   |    |      |         |        |
|     is deemed to be so competent?    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are employees tested to ensure   |    |      |         |        |
|     that training was effective?     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Are the skills or knowledge of   |    |      |         |        |
|     employees deemed competent by    |    |      |         |        |
|     virtue of experience or          |    |      |         |        |
|     education ever tested?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is training done in a serious    |    |      |         |        |
|     manner with sufficient time and  |    |      |         |        |
|     skill so that employees do not   |    |      |         |        |
|     take it as a joke?               |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Do employees believe they will   |    |      |         |        |
|     be held accountable for the      |    |      |         |        |
|     transgression of reasonable and  |    |      |         |        |
|     expected care?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Does training convey concepts of |    |      |         |        |
|     responsibility and               |    |      |         |        |
|     accountability?                  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 9. Questions to                   |    |      |         |        |
| determine implementation and effecti |    |      |         |        |
| veness of the Emergency Preparedness |    |      |         |        |
|  and Response Procedure {#questions- |    |      |         |        |
| to-determine-implementation-and-effe |    |      |         |        |
| ctiveness-of-the-emergency-preparedn |    |      |         |        |
| ess-and-response-procedure .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Have emergency preparedness and  |    |      |         |        |
|     response procedures been         |    |      |         |        |
|     established, implemented and     |    |      |         |        |
|     tested?                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Has the organization reviewed,   |    |      |         |        |
|     and where necessary, revised its |    |      |         |        |
|     emergency preparedness and       |    |      |         |        |
|     response procedures after        |    |      |         |        |
|     occurrence of accidents or       |    |      |         |        |
|     emergency situations?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Does the scope of the emergency  |    |      |         |        |
|     preparedness and response        |    |      |         |        |
|     procedures address the           |    |      |         |        |
|     prevention and mitigation of     |    |      |         |        |
|     environmental impacts?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Does the organization            |    |      |         |        |
|     periodically test such           |    |      |         |        |
|     procedures?                      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Do existing emergency procedures |    |      |         |        |
|     actually address "environmental  |    |      |         |        |
|     emergencies" as well as other    |    |      |         |        |
|     emergencies?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  When testing emergency           |    |      |         |        |
|     procedures, do the tests         |    |      |         |        |
|     exercise that portion dealing    |    |      |         |        |
|     with environmental consequences? |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Are all employees aware of       |    |      |         |        |
|     simple, immediate response       |    |      |         |        |
|     actions that can mitigate        |    |      |         |        |
|     consequences in an environmental |    |      |         |        |
|     emergency? Are they encouraged   |    |      |         |        |
|     to take such actions?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are emergency drills done with   |    |      |         |        |
|     sufficient seriousness and       |    |      |         |        |
|     realism so that employees        |    |      |         |        |
|     actually learn something from    |    |      |         |        |
|     them?                            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Has emergency planning           |    |      |         |        |
|     considered all the possible      |    |      |         |        |
|     emergencies that can occur?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Do these plans address realistic |    |      |         |        |
|     scenarios?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Are provisions sufficient to     |    |      |         |        |
|     prevent or mitigate significant  |    |      |         |        |
|     harm?                            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 10. Que                           |    |      |         |        |
| stions to determine implementation a |    |      |         |        |
| nd effectiveness of Monitoring and M |    |      |         |        |
| easurement {#questions-to-determine- |    |      |         |        |
| implementation-and-effectiveness-of- |    |      |         |        |
| monitoring-and-measurement .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are key characteristics of       |    |      |         |        |
|     significant environmental        |    |      |         |        |
|     aspects, operational controls    |    |      |         |        |
|     and progress toward objectives   |    |      |         |        |
|     and targets being monitored and  |    |      |         |        |
|     measured (e.g., record reviews,  |    |      |         |        |
|     performance observations, trend  |    |      |         |        |
|     analyses)?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the organization maintain   |    |      |         |        |
|     procedures to record information |    |      |         |        |
|     to track performance, relevant   |    |      |         |        |
|     operational controls and         |    |      |         |        |
|     progress towards the             |    |      |         |        |
|     environmental objectives and     |    |      |         |        |
|     targets?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Have performance indicators been |    |      |         |        |
|     specified within the             |    |      |         |        |
|     environmental management         |    |      |         |        |
|     programs to facilitate tracking  |    |      |         |        |
|     of progress towards objectives   |    |      |         |        |
|     and targets?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Is environmental monitoring      |    |      |         |        |
|     equipment calibrated and         |    |      |         |        |
|     maintained and are records of    |    |      |         |        |
|     this process kept according to   |    |      |         |        |
|     the organization's procedures?   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Have procedures to determine the |    |      |         |        |
|     status of compliance (e.g.,      |    |      |         |        |
|     compliance audits or             |    |      |         |        |
|     inspections) with the law been   |    |      |         |        |
|     established, and are they being  |    |      |         |        |
|     implemented?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Is the information obtained from |    |      |         |        |
|     monitoring and measurement       |    |      |         |        |
|     properly recorded and prepared   |    |      |         |        |
|     for use during the management    |    |      |         |        |
|     review?                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Is there a strong commitment in  |    |      |         |        |
|     the organization's leadership to |    |      |         |        |
|     monitoring and measurement? Do   |    |      |         |        |
|     they ask for periodic updates on |    |      |         |        |
|     measures?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Have the proper monitoring and   |    |      |         |        |
|     measurement tools been acquired  |    |      |         |        |
|     and installed appropriately?     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Have operators been trained to   |    |      |         |        |
|     read, record, calibrate and      |    |      |         |        |
|     report on the readings from      |    |      |         |        |
|     monitoring and measurement       |    |      |         |        |
|     tools?                           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Do operators exhibit a sense of  |    |      |         |        |
|     discipline and desire to         |    |      |         |        |
|     maintain the monitoring and      |    |      |         |        |
|     measurement procedures?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Are the results of monitoring    |    |      |         |        |
|     and measurement used creatively  |    |      |         |        |
|     to maintain the ISMS/EMS         |    |      |         |        |
|     momentum and to invigorate the   |    |      |         |        |
|     desire of operators to continue  |    |      |         |        |
|     their efforts?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 11. Questions to det              |    |      |         |        |
| ermine implementation and effectiven |    |      |         |        |
| ess of Communications  {#questions-t |    |      |         |        |
| o-determine-implementation-and-effec |    |      |         |        |
| tiveness-of-communications .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Have internal communications     |    |      |         |        |
|     procedures regarding ISMS/EMS    |    |      |         |        |
|     issues been established and      |    |      |         |        |
|     implemented?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the organization have       |    |      |         |        |
|     procedures for receiving,        |    |      |         |        |
|     documenting, and responding as   |    |      |         |        |
|     necessary to relevant            |    |      |         |        |
|     communication from external      |    |      |         |        |
|     interested parties?              |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Has the organization considered  |    |      |         |        |
|     procedures for external          |    |      |         |        |
|     communication of its significant |    |      |         |        |
|     environmental aspects?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Has the organization recorded    |    |      |         |        |
|     its decision on whether to have  |    |      |         |        |
|     procedures for external          |    |      |         |        |
|     communication of its significant |    |      |         |        |
|     environmental aspects?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Does the organization have       |    |      |         |        |
|     procedures to communicate with   |    |      |         |        |
|     suppliers and contractors on the |    |      |         |        |
|     environmental aspects of         |    |      |         |        |
|     supplies and on operational      |    |      |         |        |
|     controls for onsite work?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  On a periodic basis, does the    |    |      |         |        |
|     organization test the            |    |      |         |        |
|     effectiveness of its             |    |      |         |        |
|     communications to employees? Are |    |      |         |        |
|     people getting the word?         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the organization test       |    |      |         |        |
|     contractors at times, to ensure  |    |      |         |        |
|     that they have knowledge and are |    |      |         |        |
|     following required operational   |    |      |         |        |
|     controls for onsite work?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is it easy and un-intimidating   |    |      |         |        |
|     for employees to communicate up  |    |      |         |        |
|     the chain of command?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Do communications flow down to   |    |      |         |        |
|     all employees or are they prone  |    |      |         |        |
|     to blockages along the way?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Are line managers held           |    |      |         |        |
|     accountable for communications   |    |      |         |        |
|     reaching the employees under     |    |      |         |        |
|     their charge?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Are communications made simple   |    |      |         |        |
|     and logical and do they avoid    |    |      |         |        |
|     jargon? Are they translated when |    |      |         |        |
|     necessary?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 12. Questions to determine impl   |    |      |         |        |
| ementation and effectiveness of the  |    |      |         |        |
| Nonconformance and Corrective and Pr |    |      |         |        |
| eventive Actions {#questions-to-dete |    |      |         |        |
| rmine-implementation-and-effectivene |    |      |         |        |
| ss-of-the-nonconformance-and-correct |    |      |         |        |
| ive-and-preventive-actions .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are there procedures in place    |    |      |         |        |
|     that are being implemented for   |    |      |         |        |
|     handling ISMS/EMS                |    |      |         |        |
|     nonconformances?                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Do these procedures define       |    |      |         |        |
|     responsibility and authority for |    |      |         |        |
|     handling and investigating       |    |      |         |        |
|     nonconformances?                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Do they define responsibility    |    |      |         |        |
|     and authority for taking action  |    |      |         |        |
|     to mitigate any impacts caused?  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Do they define responsibility    |    |      |         |        |
|     and authority for initiating and |    |      |         |        |
|     completing corrective and        |    |      |         |        |
|     preventive action?               |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Have the corrective and          |    |      |         |        |
|     preventive actions been          |    |      |         |        |
|     appropriate to the magnitude of  |    |      |         |        |
|     the problems and impacts?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Following corrective and         |    |      |         |        |
|     preventive actions, have any     |    |      |         |        |
|     procedures that were affected by |    |      |         |        |
|     these actions been changed       |    |      |         |        |
|     accordingly?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Is the information on corrective |    |      |         |        |
|     and preventive actions being     |    |      |         |        |
|     recorded and provided to senior  |    |      |         |        |
|     management for management        |    |      |         |        |
|     review?                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are employees aware that system  |    |      |         |        |
|     failures need to be reported so  |    |      |         |        |
|     that they can be addressed as    |    |      |         |        |
|     quickly as possible?             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Do the corrective and preventive |    |      |         |        |
|     actions require an analysis of   |    |      |         |        |
|     "root causes"?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is there followup on corrective  |    |      |         |        |
|     and preventive actions to ensure |    |      |         |        |
|     they are effective?              |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Does the organizational culture  |    |      |         |        |
|     encourage employees to report    |    |      |         |        |
|     system deficiencies or does it   |    |      |         |        |
|     discourage it? (Are employees    |    |      |         |        |
|     thanked for reporting such       |    |      |         |        |
|     deficiencies?)                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Do the most competent            |    |      |         |        |
|     individuals address              |    |      |         |        |
|     nonconformances, so that         |    |      |         |        |
|     corrective and preventive        |    |      |         |        |
|     actions are the most effective   |    |      |         |        |
|     available?                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Are nonconformances being closed |    |      |         |        |
|     out completely, effectively and  |    |      |         |        |
|     timely?                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ##                                   |    |      |         |        |
| 13. Questions to determine implement |    |      |         |        |
| ation and effectiveness of the ISMS/ |    |      |         |        |
| EMS Assessment {#questions-to-determ |    |      |         |        |
| ine-implementation-and-effectiveness |    |      |         |        |
| -of-the-ismsems-assessment .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Is there a program and procedure |    |      |         |        |
|     for ISMS/EMS assessments and is  |    |      |         |        |
|     it being implemented?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Can the procedure for ISMS/EMS   |    |      |         |        |
|     assessments determine whether    |    |      |         |        |
|     the ISMS/EMS responds            |    |      |         |        |
|     appropriately to the             |    |      |         |        |
|     organization's environmental     |    |      |         |        |
|     policy?                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Can it determine whether the     |    |      |         |        |
|     ISMS/EMS conforms to the         |    |      |         |        |
|     organization's planned           |    |      |         |        |
|     arrangements for environmental   |    |      |         |        |
|     management?                      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Can it determine whether the     |    |      |         |        |
|     ISMS/EMS conforms to DOE O       |    |      |         |        |
|     450.1?                           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Can it determine whether the     |    |      |         |        |
|     ISMS/EMS had been properly       |    |      |         |        |
|     implemented and maintained?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Is the ISMS/EMS assessment       |    |      |         |        |
|     schedule based on the importance |    |      |         |        |
|     of the activities and the        |    |      |         |        |
|     results of previous assessments? |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Do the assessment procedures     |    |      |         |        |
|     cover the assessment scope,      |    |      |         |        |
|     frequency, and methodologies?    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 8.  Do the assessment procedures     |    |      |         |        |
|     cover the responsibilities and   |    |      |         |        |
|     requirements for conducting      |    |      |         |        |
|     assessments and reporting        |    |      |         |        |
|     results?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 9.  Is the information from ISMS/EMS |    |      |         |        |
|     assessments being recorded and   |    |      |         |        |
|     reported to senior management    |    |      |         |        |
|     for management review?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Do the internal ISMS/EMS         |    |      |         |        |
|     assessors have a solid           |    |      |         |        |
|     understanding of the ISMS/EMS,   |    |      |         |        |
|     its expectations, and the        |    |      |         |        |
|     requirements?                    |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Have the internal ISMS/EMS       |    |      |         |        |
|     assessors received appropriate   |    |      |         |        |
|     training to conduct ISMS/EMS     |    |      |         |        |
|     assessments?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is sufficient time allocated to  |    |      |         |        |
|     allow the internal assessors to  |    |      |         |        |
|     prepare for an assessment, to    |    |      |         |        |
|     execute it and to prepare the    |    |      |         |        |
|     reports and any followups?       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are internal assessors given     |    |      |         |        |
|     separate recognition (rewards)   |    |      |         |        |
|     for conducting ISMS/EMS          |    |      |         |        |
|     assessment when this is not      |    |      |         |        |
|     their primary function?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Is there a culture of respect    |    |      |         |        |
|     for assessors among employees?   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 6.  Do assessors see themselves as   |    |      |         |        |
|     internal consultants and         |    |      |         |        |
|     stewards of the ISMS/EMS?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 7.  Do internal assessors prepare    |    |      |         |        |
|     the assessment criteria and are  |    |      |         |        |
|     they doing this thoughtfully,    |    |      |         |        |
|     completely and with real         |    |      |         |        |
|     understanding?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 14. Questions to determi          |    |      |         |        |
| ne implementation and cohesion of IS |    |      |         |        |
| MS/EMS Documentation {#questions-to- |    |      |         |        |
| determine-implementation-and-cohesio |    |      |         |        |
| n-of-ismsems-documentation .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are the core elements of the     |    |      |         |        |
|     ISMS/EMS documented, including   |    |      |         |        |
|     all of the required procedures?  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the documentation of the    |    |      |         |        |
|     core elements of the ISMS/EMS    |    |      |         |        |
|     describe their interaction?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Does documentation of the core   |    |      |         |        |
|     elements of the ISMS/EMS provide |    |      |         |        |
|     direction to related             |    |      |         |        |
|     documentation?                   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Is the description of the        |    |      |         |        |
|     system, its components, its      |    |      |         |        |
|     details on how things will be    |    |      |         |        |
|     done and by whom complete?       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Are all references to other      |    |      |         |        |
|     systems, subsystems, procedures, |    |      |         |        |
|     programs, etc. incorporated in   |    |      |         |        |
|     the ISMS/EMS documentation?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Was the documentation compiled   |    |      |         |        |
|     with the intention that it would |    |      |         |        |
|     clearly describe the system, be  |    |      |         |        |
|     complete and serve as a          |    |      |         |        |
|     reference for those wishing to   |    |      |         |        |
|     learn about the ISMS/EMS?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Is the documentation kept        |    |      |         |        |
|     current as the ISMS/EMS evolves? |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Is documentation seen as a       |    |      |         |        |
|     necessary adjunct to a           |    |      |         |        |
|     well-working system, or is it    |    |      |         |        |
|     seen as useless red tape?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 15. Quest                         |    |      |         |        |
| ions to determine implementation and |    |      |         |        |
|  effectiveness of the Document Contr |    |      |         |        |
| ol system {#questions-to-determine-i |    |      |         |        |
| mplementation-and-effectiveness-of-t |    |      |         |        |
| he-document-control-system .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Is there a procedure for         |    |      |         |        |
|     managing and controlling the     |    |      |         |        |
|     documents that are being         |    |      |         |        |
|     implemented in the ISMS/EMS to   |    |      |         |        |
|     ensure that:                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   They can be located;             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   They are periodically reviewed,  |    |      |         |        |
|     revised as necessary, and        |    |      |         |        |
|     approved for adequacy by         |    |      |         |        |
|     authorized personnel;            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Only the current versions are in |    |      |         |        |
|     use;                             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   They are located where they are  |    |      |         |        |
|     needed;                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Obsolete documents are no longer |    |      |         |        |
|     in use;                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Documents that need to be        |    |      |         |        |
|     retained are suitably identified |    |      |         |        |
|     for that purpose.                |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Are documents legible, dated     |    |      |         |        |
|     (with dates of revision) and     |    |      |         |        |
|     readily identifiable?            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Are documents maintained in an   |    |      |         |        |
|     orderly manner and retained (if  |    |      |         |        |
|     required) for a specific period? |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Are there procedures and         |    |      |         |        |
|     designation of responsibilities  |    |      |         |        |
|     for the creation and             |    |      |         |        |
|     modification of the various      |    |      |         |        |
|     types of documents?              |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  The fewer the individuals that   |    |      |         |        |
|     are involved in document         |    |      |         |        |
|     control, the easier the task     |    |      |         |        |
|     becomes. Does the procedure for  |    |      |         |        |
|     document control minimize the    |    |      |         |        |
|     number of people that need to be |    |      |         |        |
|     involved? (The most efficient    |    |      |         |        |
|     document control is to do it     |    |      |         |        |
|     online with only one individual  |    |      |         |        |
|     responsible for making the       |    |      |         |        |
|     changes to the authorized,       |    |      |         |        |
|     official online copy.)           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  If the procedure relies on a     |    |      |         |        |
|     number of individuals, is there  |    |      |         |        |
|     one authorized coordinator who   |    |      |         |        |
|     scrupulously ensures that new    |    |      |         |        |
|     copies are properly distributed  |    |      |         |        |
|     and used while old copies are    |    |      |         |        |
|     collected and disposed?          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  When more than one individual is |    |      |         |        |
|     involved in document control, it |    |      |         |        |
|     is important to have a           |    |      |         |        |
|     well-defined procedure and       |    |      |         |        |
|     discipline to make the system    |    |      |         |        |
|     work. Does this culture prevail  |    |      |         |        |
|     in the organization?             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 16. Questions to determine imp    |    |      |         |        |
| lementation and effectiveness of the |    |      |         |        |
|  ISMS/EMS Records {#questions-to-det |    |      |         |        |
| ermine-implementation-and-effectiven |    |      |         |        |
| ess-of-the-ismsems-records .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Is there a procedure for the     |    |      |         |        |
|     identification, maintenance and  |    |      |         |        |
|     disposition of environmental     |    |      |         |        |
|     records?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Are ISMS/EMS records:            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Legible                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Identifiable and traceable to    |    |      |         |        |
|     the activity, product, or        |    |      |         |        |
|     service involved                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Stored and maintained so as to   |    |      |         |        |
|     be readily retrievable and       |    |      |         |        |
|     protected against damage,        |    |      |         |        |
|     deterioration or loss            |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Have the retention times for     |    |      |         |        |
|     ISMS/EMS records been            |    |      |         |        |
|     established and recorded?        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are the ISMS/EMS records being   |    |      |         |        |
|     retained for the periods         |    |      |         |        |
|     established?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Are the ISMS/EMS records kept to |    |      |         |        |
|     demonstrate conformance to DOE O |    |      |         |        |
|     450.1?                           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Does the prevailing culture      |    |      |         |        |
|     assign a high value to creating, |    |      |         |        |
|     storing and maintaining records  |    |      |         |        |
|     in all parts of the enterprise?  |    |      |         |        |
|     (It is unlikely that             |    |      |         |        |
|     environmental records will be    |    |      |         |        |
|     accorded a different importance  |    |      |         |        |
|     than is given to other records   |    |      |         |        |
|     produced by the organization.)   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does the organization apply      |    |      |         |        |
|     retention times to environmental |    |      |         |        |
|     records that comply with         |    |      |         |        |
|     regulatory requirements? (Is     |    |      |         |        |
|     there recognition that such      |    |      |         |        |
|     regulatory requirements need to  |    |      |         |        |
|     be researched at the time legal  |    |      |         |        |
|     and other requirements are being |    |      |         |        |
|     established for the list of      |    |      |         |        |
|     environmental aspects?)          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is responsibility for            |    |      |         |        |
|     maintaining and retrieving       |    |      |         |        |
|     records clearly established? Is  |    |      |         |        |
|     the system for doing this        |    |      |         |        |
|     reliable?                        |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Is the record system tested      |    |      |         |        |
|     periodically for its integrity   |    |      |         |        |
|     and reliability? How do we know  |    |      |         |        |
|     the system is working?           |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| ## 17. Questions                     |    |      |         |        |
| to determine implementation and effe |    |      |         |        |
| ctiveness of the ISMS/EMS Management |    |      |         |        |
|  Review {#questions-to-determine-imp |    |      |         |        |
| lementation-and-effectiveness-of-the |    |      |         |        |
| -ismsems-management-review .Table-q} |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| System Requirements:                 |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Is senior management, on a       |    |      |         |        |
|     regular basis, reviewing the     |    |      |         |        |
|     structure and performance of the |    |      |         |        |
|     ISMS/EMS to determine the        |    |      |         |        |
|     effectiveness of the ISMS/EMS    |    |      |         |        |
|     and identify potential           |    |      |         |        |
|     opportunities for improvement?   |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Do management reviews address    |    |      |         |        |
|     the possible need for changes to |    |      |         |        |
|     policy, objectives and other     |    |      |         |        |
|     elements of the organization's   |    |      |         |        |
|     ISMS/EMS, in light of            |    |      |         |        |
|     performance information, audit   |    |      |         |        |
|     results, changing circumstances  |    |      |         |        |
|     and the commitment to continual  |    |      |         |        |
|     improvement?                     |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Has sufficient information for   |    |      |         |        |
|     this assessment been reviewed,   |    |      |         |        |
|     including:                       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Monitoring and measurement       |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   ISMS/EMS assessments             |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Compliance status                |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Corrective and preventive        |    |      |         |        |
|     actions                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| -   Progress towards objectives and  |    |      |         |        |
|     targets                          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Is the review (including the     |    |      |         |        |
|     decisions taken) recorded and    |    |      |         |        |
|     are the records kept for a       |    |      |         |        |
|     suitable period of time?         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 5.  Are these management reviews     |    |      |         |        |
|     planned and organized by the     |    |      |         |        |
|     ISMS/EMS management              |    |      |         |        |
|     representative?                  |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| Root Causes:                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Does top management accept that  |    |      |         |        |
|     the top goal of an ISMS/EMS is   |    |      |         |        |
|     to change environmental culture  |    |      |         |        |
|     (That the environmental culture  |    |      |         |        |
|     is as necessary and as valuable  |    |      |         |        |
|     as the safety culture?)          |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 1.  Does top management accept that  |    |      |         |        |
|     their continued leadership and   |    |      |         |        |
|     involvement are necessary to     |    |      |         |        |
|     effect such a change in the      |    |      |         |        |
|     organization's environmental     |    |      |         |        |
|     culture?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 2.  Does top management readily      |    |      |         |        |
|     agree to participate and         |    |      |         |        |
|     contribute in the management     |    |      |         |        |
|     reviews?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 3.  Is top management aware of and   |    |      |         |        |
|     does it believe in the potential |    |      |         |        |
|     benefits of having a             |    |      |         |        |
|     well-established environmental   |    |      |         |        |
|     culture?                         |    |      |         |        |
+--------------------------------------+----+------+---------+--------+
| 4.  Are management reviews focused   |    |      |         |        |
|     on the results of the system and |    |      |         |        |
|     do they consider sufficiently    |    |      |         |        |
|     the evaluation and authorization |    |      |         |        |
|     of changes to promote progress   |    |      |         |        |
|     and continual improvements?      |    |      |         |        |
+--------------------------------------+----+------+---------+--------+

1.  Completing the Assessment

After the assessment is conducted, the assessment team should hold a
closing meeting to complete the assessment by discussing the findings
and agreeing to followup actions to address the findings. In preparation
for this meeting, the assessment team should prepare a Findings and
Summary Report. The Assessment Findings Summary Table template and the
Assessment Summary report template in sections C.3.1 and C.3.2. below
can be used to assist the assessment team in preparing a Findings and
Summary Report.

The assessment team may also prepare a corrective action report (CAR). A
template that can be used to develop a CAR is in section C.3.3 below.

1.  Assessment Findings Summary Table

![](media/image20.wmf){width="6.470138888888889in"
height="5.289583333333334in"}

2.  Assessment Summary Report Template

![](media/image21.wmf){width="6.477083333333334in"
height="7.297916666666667in"}

3.  Corrective Action Report Template

![](media/image22.wmf){width="6.4840277777777775in"
height="6.652083333333334in"}

# APPENDIX D GLOSSARY {#appendix-d-glossary .App1}

**GLOSSARY**

**Activities, Products, and Services**---A catchall phrase that was
developed by Technical Committee 207 of ISO to capture all of the
elements at a facility or organization that can interact with the
environment.

**Assessment**---see ISMS/EMS Assessment.

**Audit**---A systematic and documented verification process of
objectively obtaining and evaluating evidence to determine the adequacy
of a program or system within an organization.

**Compliance Audit**---A systematic and documented verification process
of objectively obtaining and evaluating evidence to determine the status
of a DOE program regarding compliance with laws, regulations, and DOE
Orders.

**Continuous Improvement**---The process of enhancing the environmental
management system to achieve improvements in overall environmental
performance in line with the organization's environmental policy. This
process need not take place in all areas of activity simultaneously.

**Corrective Action**---An action taken to eliminate the causes of an
existing noncompliance, nonconformity, defect, or other undesirable
situation in order to prevent recurrence.

**Cultural Resources**---Historic properties as defined in the National
Historic Preservation Act, archaeological resources as defined in the
Archaeological Resources Protection Act, and cultural items as defined
in the Native American Graves Protection and Repatriation Act. Include
artifacts and sites dating to the prehistoric, historic, and
ethnohistoric periods that are currently located on the ground or buried
beneath it; standing structures that are more than 50 years of age or
are important because they represent a major historic theme or era;
cultural and natural places, select natural resources, and sacred
objects that have importance for Native Americans and other ethnic
groups; and American folklife traditions and arts.

**Environment**---Surroundings in which an organization operates,
including air, water, land, natural resources, flora, fauna, humans, and
their interrelation (ISO-14001, 1996).

**Environmental Aspect**---Elements of an organization's activities,
products, or services that can interact with the environment (ISO-14001,
1996) (The environmental aspect of an activity is that part of it that
creates a possibility for an environmental impact. As such, it is
equivalent to the concept of "hazard" in safety, which is also defined
as the mere possibility of a negative event.)

**Environmental Impact**---A change to the environment, whether adverse
or beneficial, wholly or partially resulting from an organization's
activities, products, or services (ISO-14001, 1996).

**Environmental Management System (EMS)**---The part of the overall
management system that includes organizational structure, planning
activities, responsibilities, practices, procedures, processes, and
resources for developing, integrating, achieving, reviewing, and
maintaining environmental policy; a continuing cycle of planning,
implementing, evaluating, and improving processes and actions undertaken
to achieve environmental goals.

**Environmental Objective**---An overall environmental goal, arising
from the environmental policy, that an organization sets itself to
achieve, and which is quantified where practicable (ISO‑14001, 1996).

**Environmental Performance**---Measurable results of the environmental
management system, related to an organization's control of its
environmental aspects, based on its environmental policy, objectives,
and targets (ISO-14001, 1996).

**Environmental Policy**---A statement by the organization of its
intentions and principles in relation to its overall environmental
performance, which provides a framework for action and for the setting
of its environmental objectives and targets (ISO-14001, 1996).

**Environmental Target**---A detailed performance requirement,
quantified where practicable, and applicable to the organization or
parts thereof, which arises from the environmental objectives and needs
to be set and met to achieve those objectives (ISO-14001, 1996).

**Gap Analysis**---An assessment of EMS requirements against existing
management system descriptions, policies, and procedures.

**Integrated Safety Management System (ISMS)**---A DOE management system
that provides a formal, organized process whereby people plan, perform,
assess, and improve the safe conduct of work efficiently and in a manner
that ensures protection of workers, the public, and the environment.
This management system shall be used to systematically integrate safety
into management and work practices at all levels so that missions are
accomplished while protecting the public, the worker, and the
environment.

**ISMS/EMS Assessment (Assessment)**---A formal self-assessment (see
self-assessment) that is normally conducted by an organization with an
appropriate degree of independence.

**ISO Audit/ISO 14001 EMS Audit**---an audit that is used as a vehicle
through which the environmental aspects of an organization and how they
are managed are systematically compared against the requirements of the
ISO 14001 specification.

**ISO-14001 Standard**---Internationally recognized voluntary
environmental management system standard that provides organizations
with the elements of an effective environmental management system that
can be integrated with other management requirements to help
organizations to achieve environmental and economic goals.

**Likelihood**---A measure of how often an aspect can be expected to
occur within an activity given the probability of its occurrence for
each repetition of the activity and the frequency of the activity over
time.

**Operational Controls**---Procedures that help a site in implementing
its environmental policy, objectives, and targets.

**Organization**---A company, corporation, firm, enterprise, authority,
or institution, or part or combination thereof, whether incorporated or
not, public or private, that has its own functions and administration
(ISO-14001, 1996).

**Pollution Prevention**---A source reduction as defined in the
Pollution Prevention Act and other practices that reduce or eliminate
the creation of pollutants through (1) increased efficiency in the use
of raw materials, energy, water, or other natural resources or (2)
protection of natural resources by conservation. The DOE has expanded
this definition to include recycling.

**Pollution Prevention Opportunity Assessment**---an appraisal conducted
to identify those processes, projects and operations that need to be
improved or replaced to promote pollution prevention, including waste
minimization and energy conservation. A pollution prevention opportunity
assessment (PPOA) documents material and energy usage, project size,
process by‑products, equipment, and waste generation. The assessment
consists of a systematic approach which includes the following: (1)
organization of PPOA teams, (2) assessment of waste‑producing
activities, (3) development and evaluation of pollution prevention
opportunities, and (4) recommendations for implementation of pollution
prevention options.

**Potential Environmental Impact**---An aspect defined by its likelihood
of occurrence and likely consequences. It is equivalent to the concept
of "risk" in Safety, which assigns a probability and consequence to the
possible negative event that may result from a "hazard."

**Recycling**---(1) The use or reuse of a material as an effective
substitute for a commercial product and as an ingredient or feedstock in
an industrial or energy-producing process and (2) the reclamation of
useful constituents within a waste, or removal of contaminants from a
waste to allow it to be reused.

**Root Cause**---The origin of an environmental deficiency.

**Self-Assessment**---An analysis or evaluation, that can be informal or
formal and structured, of a DOE program or contractor management system
by that program or contractor to ensure conformance to regulatory and
DOE internal requirements and to confirm the safe and environmentally
protective performance of work.

**Self-Declaration**---An organization determines that it is in full
conformance with the requirements of DOE O450.1 and publicly asserts
that it conforms to these requirements.

**Self-Declaration Evaluation**---An evaluation conducted by an
organization for the purpose of determining whether its Environmental
Management System is in full conformance with the requirements of DOE O
450.1.

**Significant Environmental Aspect**---An environmental aspect that has
or could have a significant impact on the environment, the organization,
or to the organization's mission (ISO‑14001, 1996).

**Senior Management**---The level of management that has the authority
to make decisions for the site or facility.

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[^1]: Secretary of Energy Memorandum, "Pollution Prevention and Energy
    Efficiency Leadership Goals for Fiscal Year 2000 and Beyond,"
    November 12, 1999.

[^2]: Nonattainment areas are areas not meeting one or more NAAQS, and
    maintenance areas are former nonattainment areas now in attainment,
    with an approved maintenance plan to stay in attainment.

[^3]: American National Standards Institute and American Society for
    Quality Control E-4 (ANSI/ASQC E4-1994) was selected as the basis
    for the intergovernmental quality system because it is a national
    standard that specifically addresses environmental data collection
    and use and environmental technology. Part A, Management Systems,
    describes the quality management elements needed for managing
    environmental programs effectively. These include: management and
    organization, quality system and description, personnel
    qualification and training, procurement of items and services,
    documents and records, computer hardware and software, planning,
    implementation of work processes, assessment and response, and
    quality improvement.

[^4]: ANSI/ASQC E-4 Part B, "Collection and Evaluation of Environmental
    Data." It addresses project-specific requirements needed to plan,
    implement, and assess environmental data operations, including the
    collection, handling, analysis, and evaluation of
    environmental-related data. Such data include: chemical, biological,
    toxicological, and radiological data.