# Presentation: 495075

## BNL Environmental Management System Project 

**S. L. K. Briggs**
- Presentation to management reps on EMS, 9/14/00

## Meeting Agenda

**Purpose:** Exchange information on BNL EMS Registration process
**Summary of Registration Process**
**Summary of Independent Oversight Office Audit**
**Year 3 Audit Process**
**Preparation for Year 3 Audit**
**Updates and loose ends**
**Q&A**
**Next Meetings**

## Independent Oversight Office Audit complete 8/11/00
Documentation appropriately addresses all 17 requirements
Organizations commitment to continuous improvement evident
Operational controls well documented and effectively implemented
Staff, including visitors, uniformly aware of environmental impacts, P2, & EMS
Official* (and unofficial) findings/observations
Not following Aspects procedure* 
Document control issues (EMS Manual not controlled; out-of-date procedures in workplace; no approvals, rev date/# )
Annual review of Process Evaluations not done 
Non-Compliance issues not addressed (EMP; exemption)
In-Consistency/accuracy/completeness within and between documents (EMP, Op Controls, ESR, Aspects)
EMS documentation not explicit on “who” & “how” each element is satisfied within organizations

- Documentation appropriately addresses all 17 requirements
- Organizations commitment to continuous improvement evident
- Operational controls well documented and effectively implemented
- Staff, including visitors, uniformly aware of environmental impacts, P2, & EMS
- Official* (and unofficial) findings/observations
- Not following Aspects procedure*
- Document control issues (EMS Manual not controlled; out-of-date procedures in workplace; no approvals, rev date/# )
- Annual review of Process Evaluations not done
- Non-Compliance issues not addressed (EMP; exemption)
- In-Consistency/accuracy/completeness within and between documents (EMP, Op Controls, ESR, Aspects)
- EMS documentation not explicit on “who” & “how” each element is satisfied within organizations

**EMS Assessment Initiatives**

**Notes:**
In addition to internal assessments, there have been two major external audits of the EMS conducted

1st the I/O office coordinated an assessment within several Directorates to confirm that the EMS has been implemented
here are results...I would like to highlight 2:
Organizations commitment to continual improvement evident (self assessment, nonconformance corrective action programs)
Both staff and visitors were aware of environmental impacts, P2 and EMS
this was not the case just 2 months earlier, and  reflects the concerted efforts made by your team members to enhance the awareness.

2nd the formal registration audits by an independent accredited registrar:
again to highlight their findings,
they commended our P2 program and  noted several individual efforts
commended the strong line organization involvement (not just the E support org)
audit team submitted their recommendation for registration
It was the combination of results from these two assessments that enabled Dr.Marburger to Self Declare Conformance to ISO 14001 for BNL and meet one of the contract requirements.

## Registration Audits complete 8/25/00
Several noteworthy practices in Pollution Prevention observed
EMS integrated with other management systems
Line organizations fully involved in EMS implementation
Recommendation for registration to ISO 14001
CONGRATULATIONS BNL ISO 14001 REGISTERED FACILITIES
Superconducting Magnet Division       Collider – Accelerator Department
Biology Department		             Medical Department
Brookhaven LINAC Isotope Producer and Target Processing Laboratory
Waste Management Division 	             Environmental Restoration Division
Reactor Division 

- Several noteworthy practices in Pollution Prevention observed
- EMS integrated with other management systems
- Line organizations fully involved in EMS implementation
- Recommendation for registration to ISO 14001
- CONGRATULATIONS BNL ISO 14001 REGISTERED FACILITIES
- Superconducting Magnet Division       Collider – Accelerator Department
- Biology Department		             Medical Department
- Brookhaven LINAC Isotope Producer and Target Processing Laboratory
- Waste Management Division 	             Environmental Restoration Division
- Reactor Division** **

**EMS Assessment Initiatives**

- Registration
- Approved
- 9/12/00

**Notes:**
In addition to internal assessments, there have been two major external audits of the EMS conducted

1st the I/O office coordinated an assessment within several Directorates to confirm that the EMS has been implemented
here are results...I would like to highlight 2:
Organizations commitment to continual improvement evident (self assessment, nonconformance corrective action programs)
Both staff and visitors were aware of environmental impacts, P2 and EMS
this was not the case just 2 months earlier, and  reflects the concerted efforts made by your team members to enhance the awareness.

2nd the formal registration audits by an independent accredited registrar:
again to highlight their findings,
they commended our P2 program and  noted several individual efforts
commended the strong line organization involvement (not just the E support org)
audit team submitted their recommendation for registration
It was the combination of results from these two assessments that enabled Dr.Marburger to Self Declare Conformance to ISO 14001 for BNL and meet one of the contract requirements.

## Official Nonconformances* & Opportunities for Improvement
Objectives/Targets
some of the organizations E goals were not included in their EMS (on EMP)*
no objective evidence of management concurrence 
are not established for FRDP/Legacy issues*
EMPs
incomplete information (program description, actions, due dates)*
do not address all of the significant aspects in an organization*
Operational Controls for Legacy issues (i.e., FRDP) not documented
Emergency Response procedures 
do not include requirement to review/revise after drills or incident
Not up-to-date*
Audit schedules do not take into account the environmental importance of activity or results of previous audits*

- Objectives/Targets
- some of the organizations E goals were not included in their EMS (on EMP)*
- no objective evidence of management concurrence
- are not established for FRDP/Legacy issues*
- EMPs
- incomplete information (program description, actions, due dates)*
- do not address all of the significant aspects in an organization*
- Operational Controls for Legacy issues (i.e., FRDP) not documented
- Emergency Response procedures
- do not include requirement to review/revise after drills or incident
- Not up-to-date*
- Audit schedules do not take into account the environmental importance of activity or results of previous audits*

**EMS Assessment Initiatives**

**Notes:**
In addition to internal assessments, there have been two major external audits of the EMS conducted

1st the I/O office coordinated an assessment within several Directorates to confirm that the EMS has been implemented
here are results...I would like to highlight 2:
Organizations commitment to continual improvement evident (self assessment, nonconformance corrective action programs)
Both staff and visitors were aware of environmental impacts, P2 and EMS
this was not the case just 2 months earlier, and  reflects the concerted efforts made by your team members to enhance the awareness.

2nd the formal registration audits by an independent accredited registrar:
again to highlight their findings,
they commended our P2 program and  noted several individual efforts
commended the strong line organization involvement (not just the E support org)
audit team submitted their recommendation for registration
It was the combination of results from these two assessments that enabled Dr.Marburger to Self Declare Conformance to ISO 14001 for BNL and meet one of the contract requirements.

## Official Nonconformances* & Opportunities for Improvement
EMS Documentation lacks
description of how progress in achieving objectives/targets is monitored
internal/external communication processes
Missing one 90-day weekly inspection record*
Process Assessment Form not consistent (up-to-date) with OCF*
Internal records procedure lacked retention times*
CAA Tracking system can not identify/distinguish EMS-related NC
Training:
Employee lacked required training*
databases provided conflicting information
job specific training program did not identify all applicable aspects
Note: Complex EMS with overlapping systems; interdependence amongst parts; changes in one affect others; updates must be comprehensive 

- EMS Documentation lacks
- description of how progress in achieving objectives/targets is monitored
- internal/external communication processes
- Missing one 90-day weekly inspection record*
- Process Assessment Form not consistent (up-to-date) with OCF*
- Internal records procedure lacked retention times*
- CAA Tracking system can not identify/distinguish EMS-related NC
- Training:
- Employee lacked required training*
- databases provided conflicting information
- job specific training program did not identify all applicable aspects
*Note: Complex EMS with overlapping systems; interdependence amongst parts; changes in one affect others; updates must be comprehensive *

**EMS Assessment Initiatives**

**Notes:**
In addition to internal assessments, there have been two major external audits of the EMS conducted

1st the I/O office coordinated an assessment within several Directorates to confirm that the EMS has been implemented
here are results...I would like to highlight 2:
Organizations commitment to continual improvement evident (self assessment, nonconformance corrective action programs)
Both staff and visitors were aware of environmental impacts, P2 and EMS
this was not the case just 2 months earlier, and  reflects the concerted efforts made by your team members to enhance the awareness.

2nd the formal registration audits by an independent accredited registrar:
again to highlight their findings,
they commended our P2 program and  noted several individual efforts
commended the strong line organization involvement (not just the E support org)
audit team submitted their recommendation for registration
It was the combination of results from these two assessments that enabled Dr.Marburger to Self Declare Conformance to ISO 14001 for BNL and meet one of the contract requirements.

## Labwide Corrective Actions

**Preventive actions to address similar issues elsewhere in system**
- All Management Reps:
- Review EMPs (or equivalent documentation) to verify that their Directorates/Dept/Div EMPs capture the complete list of environmental improvements authorized and initiated
- Make suggestions for modification to Laboratory guidance (subject areas, program descriptions, etc.) or development of new guidance on this or related topics that would be needed to prevent recurrence of this nonconformance.
- Due date 9/30/00; tracked in ATS
- EMS Project Personnel: Update Procedure on Establishing and Implementing Environmental Objectives
- Emergency Planning Group: Update Procedure on Local Emergency plans and Critiques

## Other Registration lines of inquiry & “findings”

**Environmental Support Organizations should manage all activities within the ISO 14001 framework**
- ESD, ERD, WMD
- Lab-level responsibilities as well as facility level (i.e., horizontal/vertical)
- Also applies to other support organizations with key EMS responsibilities - CIGPA/DO, PPM, ESHQ Offices -- manage programs in accordance with the respective ISO requirement
**Better knowledge of support organizations services to line**
**Are offsite activities performed in accordance with EMS requirements?**
- Know when response is “yes”; when “no”; if “no” how?
**Are all E related goals managed within EMS program?**
- Do EMPs capture all the E objectives/targets?
- Do EMPs capture all activities that are currently going on?

## Overview:
Desk Audit (Documentation Review): 9/25-26/00
Onsite Audit: 10/23-27/00
Directorates: HENP, BES, EENS, FO, ESHQ, DO/CIGPA, FA
Scope defined in Year 3 Audit Plan
Desk Audit Process: 
See NSF Procedure & report from Registration audit
Response due by 10/11/00
documented response providing additional explanation and clarification, plus specific reference to supporting procedures as required
Onsite Audit begins with item by item explanation.

**Desk Audit (Documentation Review): 9/25-26/00**
**Onsite Audit: 10/23-27/00**
**Directorates: HENP, BES, EENS, FO, ESHQ, DO/CIGPA, FA**
**Scope defined in Year 3 Audit Plan**
**Desk Audit Process: **
- See NSF Procedure & report from Registration audit
- Response due by 10/11/00
- documented response providing additional explanation and clarification, plus specific reference to supporting procedures as required
- Onsite Audit begins with item by item explanation.

- DOE/EPA Memorandum of Agreement Audit

**Notes:**
Transition EMS Project----> EMS Program
logistical issues, like
Reduce frequency of EMS Project team meetings 
document completion of the key project deliverables 

Focus for the organizations in the upcoming year will be on: streamlining the programs, integrating them  better into existing dept/div programs, and continual improvement 

Organizations also have to preparing  for upcoming external reviews
The next one is the third DOE/EPA  Audit required under the MOA,   (give details)
and the Site wide Registration Audit next spring

## DESK AUDIT DOCUMENTS

**COMPILE DOCUMENTS FOR AUDITORS: **
**EMS Program Description (dir/dept/div “EMS Manual”)**
**Aspects spreadsheet* **
**EM Program forms***
**Self Assessment Report***
**Management review***
**	****- presentation and minutes**
**Organization Chart**
**Key contacts list**
****Plus any internal procedures that augment SBMS***
**Submit 3 copies to B. Cox by 9/20/00**

## Onsite Audit

**Starts with presentations by Mgmt Reps**
- Topics: mission, operations, aspects, organizational profile
- 15 min Maximum!  10/23/00, 8:00 a.m., Location: Bldg. 535
- team members welcome
**Opening meeting 10/23 tentatively 10:30 a.m., Location: Bldg. 535**
- Managers expected to attend
- NSF runs meeting and explains process
**Audit begins 10/23/00, 11:00 a.m.**
- Two audit teams; possible observers
- Expect one full day at your facility
- starts with team meeting, followed by interviews of selected work groups
**Debriefs each day: 5:00 -5:30, Location:  Bldg. 535**
**Closing meeting 10/27 tentatively 3:00 pm, Location:  Bldg. 535**

## Onsite Audit

**Audit Schedule**
- Schedule of facilities/groups will be issued
- Need to be flexible & anticipate early/late arrivals--be ready before your scheduled interview slot
- ADVISE ME ASAP OF ANY SIGNIFICANT CONFLICTS FOR THAT WEEK
**Facility Audit format**
- Tour ~ 1 hour
- Resolution of Desk Audit Issues
- In depth review of select ISO requirements
- Interview of employees
- Reserve a local conference room in your facility to meet
- Have key team members readily available
**Transmit NCRS/OI to me ASAP**
**Address any Compliance issues to B. Zimmerman/R. Lee immediately...**Then, get message to me that one is identified.

## Onsite Audit Preparation

**Review ISO requirements and your facility programs**
- Audit team not only looking at process implemented but focused on how it will be maintained up-to-date (processes used to incorporate new or modified activities)
**Lab-level documentation will be provided to auditor (see TOC)**
**Organize/Prepare facility-level documentation (hard-copy)**
- Include procedures & records (objective evidence)
- Recommend preparing flowcharts/cheat sheets to describe process implemented
- Use EMPs and OCF documents to explain linkages between program elements
**Walk through facility where interviews/tours will be conducted--address any compliance and housekeeping issues before hand**
**Prepare/Brief Staff before visit**
- Managers, Team members, Staff

## Onsite Audit - Document Preparation

**EMS Documentation**
**Internal procedures**
**Tier I reports**
**Tracking records - notices, databases printouts**
**Air Emission logbooks**
**90 day area inspections reports **
**Operational Control records**

**Training records (BTMS) **
**Job descriptions/R2A2 **
**Notices of new/changes to legal requirements **
**Print outs from the Phase II database **
**Nonconformances/**
**	****Corrective Actions**
**EMS Assessments/Mgmt Review [corrective actions *****in action]***
***Work Permits***
***ORPS***

## Preparations for Onsite Audit

**Implementation team briefings**
- Process implemented
- SBMS documents/procedures
- Internal documents/procedures
- See examples on EMS Website (project team meeting 6/8/00)
**Team member familiarity with:**
- SBMS documents
- NSF Audit procedure (see exhibit in Env. Assessments Subject Area)
**Manager briefings**
- Policy, communications, EMS Audits/Self Assessment, Management Review
*See extended ops council briefing on EMS website*

## Audit Deliverables

**Submit 3 copies of EMS Documents to B. Cox by 9/20/00**
**Schedule interviews**
- Level 1 & 2 manager interviews will be scheduled (by B. Cox)
- Provide list of contacts/locations to B. Cox by 10/19/00
**Review and respond to Desk Audit Issues/comments**
- Receive desk audit report ~10/4/00
- Submit  responses to me by 10/11/00 (seek consult and submit earlier if available)
- Consider including responses in next revision of EMS Documentation
**Opening Meeting* on 10/23/00 (10:30 am, Bldg. 535)**
- Give presentation on Organization/Activities/Aspects 8:00 a.m., Bldg. 535
**Escort Auditor to & from interviews/cafeteria/caucus meetings**
- Notify me of any & all NCRs, OI, noncompliances ASAP (fax Ext. 5845)
- Develop corrective & preventive actions (using ATS action forms) *ASA-Practical*
**Attend debrief meetings each evening ~5:00pm, Bldg. 535**
**Attend Closeout Meeting* 10/27 ~3:00pm, Bldg. 535**
****Managers presence requested***

## Auditee Tips and Techniques

**Answer the question posed **
- Take time to think and formulate your response
- If you don’t understand the question ask for clarification
- If it is a Yes/No question, answer “yes” or “no”
- If you want someone present, request it
**It’s okay to say “I don’t know”**
- Don’t oversell your expertise -- If you are not the key contact on the subject, defer to others
- Don’t answer questions if you are not personally knowledgeable

## Auditee Tips and Techniques

- Silence--do not feel obliged to fill void with verbiage
- Don’t volunteer additional/tangential information
- Be Honest, Friendly, Polite, Respectful, and Professional
- Be truthful about problems, but be sure to mention what actions are planned or were taken to correct problem
- Portray a Positive Attitude in Support of BNL changes
- This is not a forum for airing your complaints
- use available channels -- follow management chain
- Audits = findings = resources
- Focus our resources on our Self Assessment findings & priority issues
**Questions or concerns?**

## Hot “E” Topics – Performance Measures

**Preventive actions on increasing spills trend**
- Focus on activities with petroleum products
- Implement rigorous preventative maintenance
- Change to non-petroleum-based products (vegetable oils)
- Driving practices – stay on road; avoid exposed stakes
- Don’t overfill fuel tanks
**Preventive actions on SPDES violations**
- Review/evaluate controls for potential liquid discharge sources – enhance!
- 	**Note:  It only took 1.5 oz of perchloroethylene to cause exceedance**
- Exceedances varied in constituent (no obvious trend); occurred between April – July (are we training/advising students of EMS procedures adequately?)
- 4/00 – Suspended solids; 5/00 – zinc; 6/00 – iron, perchloroethylene;
- 	7/00 – oil/grease

## Hot “E” Topics - Miscellaneous

**Iniatives to enhance procurement controls**
- Prevent purchase of hazardous products when exact equivalent product available
- Zepreserve
- Ultrajet
- Automatic denials versus flagging
**GIS capability to visually display information**
- Display multiple data in overlapping layers; 3D
- Possibly use to locate/view significant aspects
- Any interest/value for EMS Program?

## Other Issues

**Enter Job-Specific Training Records into BTMS**
- Links made to employee JTAs
- Consider links to other department staff positions
- Review ISO 14001 “Plus” EMS Manual Revision
- Cites new SBMS documents published during the last year
- Text was revised for clarification purposes
- Added reference to some existing BNL programs to  conform to EPA guidance for a “Compliance Focused Environmental management System Manual”
- Distribute EMS Cards, poster, mouse pads
- Review status of EMP tasks -- see Phase II CA summary table
**Finalize Documentation Deliverables list**

## Next Meetings

**Next EMS Meeting 10/12/00 **
- Time: 1:30 pm - 3:00 pm
- Location - 535 Conference Room
*NOTE: EMS Project Team Meetings held on 2nd Thursday of each month*
*CHANGED to monthly meetings*
**Topics:**
- Preparations for Year 3 Audit
- Environmental Compliance Assessments
- FY 01 Environmental Priorities
- EMS Maintenance/Continual Improvement tasks
- Others?