# Presentation: 231017

## BNL Environmental Management System Project 

- S. L. K. Briggs
**Presentation to management reps on EMS, 3/8/01**

## Meeting Agenda

**Purpose: Exchange information on BNL EMS Implementation process**
- Revisions to EMS Subject Areas
- Update on Lab-level EMS Audit
- Prep for Registration Audit
- Site Specific Records Schedule - DEMO
- EMS Program 2001 Status
- Status of EMS ATS Items
- Other Issues & Announcements
- Q&A
- Next Meetings

## EMS Subject Area Revisions

_**Identification of Significant Aspects Subject Area**_
**Aspects subprocedure**
- Eliminated Aspects Summary Form
**Objectives/Targets & EM Programs subprocedure**
- References Integrated Assessment Subject Area
- “Guidelines for Developing Objectives & Performance Measures”
- “Self Assessment Program Requirements”
- Provides option to use Self Assessment Plan in lieu of EMP
- Clarifies EM Program requirements and provides cross reference between SAP and EMP elements
- Eliminates redundant fields on EMP Form
- Provides guidance on demonstrating management concurrence
- Adds clarifying language to steps to facilitate implementation
- See *https://sbms-authqa.bnl.gov/standard/0m/0m02d011.htm*

## EMS Subject Area Revisions

_**Environmental Assessments**_
- Regulatory Compliance Assessments
- Taking credit for annual review of PEP/ESR and Tier I
- Augment, as needed, with focused assessment in a specific regulatory area, ie., waste, tanks, liquid discharges
- Eliminate requirement to audit all regulatory topics annually
- References new subject areas related to Assessments
- ATS, Tier I, Integrated Assessment, Environmental Evaluation of Industrial/Experimental Processes, Records, Training/Qualification
- Provides flexibility in audit planning and documentation (by deferring to Tier 1, PEP/ESR procedures)
- Addresses corrective actions from previous audit findings
- Revised Checklist; Complete each checklist item (yes/no/not applicable);
- Assess all 17 elements annually; Include objective evidence in comment section
- Adds clarifying language to facilitate implementation

## Laboratory Level EMS Audit

**Dates:** January 12-February 12, 2000
**Audit Team:** E. Zimmerman (PNNL), M. Buckley and M. Van Essendelft (BNL)
**Scope:** BNL EMS design and maturity, conformance to ISO 14001 and MOA, implementation throughout the Lab.
**Approach:**  Review of 78 internal and external assessments from 1998-present, management reviews, documents, plus interviews with management system stewards or program leads.  **Designed to minimize impact on line, summarize and trend wealth of existing audit data.**

## Categorization of Findings:
0  Major Nonconformances: Element Missing, not implemented or ineffective.
7 Minor Nonconformances: Single observed discrepancy in system with evidence that overall system is defined, implemented and effective.
19 Observations: Could lead to a nonconformance if not addressed/inadequate evidence to support nonconformance.
35 Trends: Prevailing tendency seen in previous audits/mgmt reviews. Most have been/are being corrected.
77 Opportunities for Improvement/Recommendations: Suggested means of improving EMS.
22 Noteworthy Practices: Performance exceeds expectations.

**0  Major Nonconformances: **Element Missing, not implemented or ineffective.
**7 Minor Nonconformances: **Single observed discrepancy in system with evidence that overall system is defined, implemented and effective.
**19 Observations:** Could lead to a nonconformance if not addressed/inadequate evidence to support nonconformance.
**35 Trends:** Prevailing tendency seen in previous audits/mgmt reviews. Most have been/are being corrected.
**77 Opportunities for Improvement/Recommendations: **Suggested means of improving EMS.
**22 Noteworthy Practices: **Performance exceeds expectations.

**Laboratory Level EMS Audit****Audit Results**

## Laboratory Level EMS AuditGeneral Findings

- Number of findings reflects number and depth of assessments reviewed rather than overall adequacy of system, which is clearly evident.
- BNL’s EMS is still maturing, and for some elements is in midst of first or second improvement cycle.  Probably most developed and complete of all BNL management systems.
- Value-added has been recognized in audits and Management Reviews.

## Laboratory Level EMS AuditRecognized Value Added of EMS

- EMS strengthened, integrated with other management systems, formalized and systematic.
- Line ownership for environmental stewardship, R2A2s defined.
- Comprehensive environmental training program.
- Improved understanding of environmental aspects and requirements.
- Documents and procedures up-to-date, formalized.
- Success in achieving environmental goals.
- Improved communication.
- Core EMS teams cutting across organizations.

## Laboratory Level EMS AuditMinor Nonconformances

- Stormwater requirements in Best Management Practices Manual not incorporated into SBMS. (ESD)
- P2 Program Description (=EMP) does not document means and time frame for achieving objectives. (ESD)
- Chemistry EMS Description is available in two versions online--one controlled, one not. (Chemistry)
- EMS Project Communications Plan (internal controlled doc) doesn’t have an approval or revision letter or number. (ESD)
- Neither SBMS nor EMS Manual adequately address periodic review requirement for procedures/EMS documentation. (EMS/SBMS)
- EMS Rep responsibilities transferred, but responsibility for corrective action follow-up was not transferred; ATS actions overdue. (ERD)
- No records retention schedule established as of 2/12/01. (ISD)

## Laboratory Level EMS AuditKey Observations for EMS Reps to Consider

- Table 4.1.5 (FUA) not up-to-date or complete. (ESD)
- As a result of budgeting process, some important activities delayed due to resource/responsibility decisions.
- Line managers may not realize their role in Critical Outcomes. (IAP)
- Confusion over effective vs. issue vs. revision dates could result in use of an SBMS document that is not the most recent. (SBMS)
- EIMS database not up-to-date or complete. Still no mechanism to facilitate generation of facility monitoring reports. (ESD)
- Lack of follow-through on audit observations, opportunities for improvement.

## Laboratory Level EMS AuditNoteworthy Practices EMS Reps should be Proud

- Integration of aspect analysis and EMS maintenance into Experimental Safety Review process and conduct of ops.
- Exceptional job identifying activities which could potentially impact groundwater.
- ECR’s are consistently involved in Tier 1’s.
- Strong management support at briefings on environmental objectives and targets.
- Thorough assessment of EMS by line.
- EMS project and reps have done a great job of tracking, trending, sharing lessons learned, continual improvement.
- Usage of Family-Level ATS.
- Informative, constructive and productive management reviews.

## Laboratory Level EMS AuditNext Steps

- Read Audit Report.
- LOTS of information, some organization-specific not reviewed in this presentation.
-  Will be summarized at Labwide EMS Management Review on 4/4/01, 9:30-11:00 a.m.
- USE information for continual improvement:
- Follow-up on minor nonconformances.
- Prioritize observations, trends, and opportunities for improvement.
- Develop and implement action plans.
- Prepare for registration audit.
- Questions?

## Desk Audit by Registrar on 3/5-3/6/01 
CAD, PE, ERD, HFBR, BLIP/TPL
Onsite Readiness Review on 5/9 – 5/10/01 (2 auditors)
Orientation: Lab level program on aspects; CO/O/PM and flowdown to objectives/targets and EM Programs; assessment and management review
Resolution of Desk Audit Issues
Preparedness check in 1 or 2 facilities:
Tour, facility presentation, then discussion on aspects, objectives/targets, EM Program, assessment and management review
More time in fewer facilities; focus is on consistency in implementation
Registration Audit on 6/18 – 6/22/01(4 auditors)

- CAD, PE, ERD, HFBR, BLIP/TPL
**Onsite Readiness Review on 5/9 – 5/10/01 (**2 auditors)
- Orientation: Lab level program on aspects; CO/O/PM and flowdown to objectives/targets and EM Programs; assessment and management review
- Resolution of Desk Audit Issues
- Preparedness check in 1 or 2 facilities:
- Tour, facility presentation, then discussion on aspects, objectives/targets, EM Program, assessment and management review
- More time in fewer facilities; focus is on consistency in implementation
- Registration Audit on 6/18 – 6/22/01(4 auditors)

**Preparation for Registration Audit**

## Registration Audit Scope

_**Approach:**_** one sitewide registration, *****as opposed to facility registration audits and surveillances***
- Focus on Management System Owner, with sampling of implementation in Depts/Divs
- Doct Control, Records, Emg Prep/Resp, Training, Communications, Legal/Other Reqmts
- Focus at higher risk facilities: *CAD, PE, ERD, HFBR, BLIP/TPL, WMD *
- Policy, Aspects, Objectives/Targets, EM Programs, Structure & Responsibility, Communication, Operational Controls, Monit & Meas, Nonconformance CA/PA, EMS Audit, Management Review
- Focus for ESD
- Internal operations: Policy, Structure/responsibility, Communication, Monit & Meas (Rad Con Div – Instr),
- Lab-level program responsibility: Policy, Aspects, Legal/Other Reqmts, Objectives/Targets, EM Program, Structure & Responsibility, Training, Communication, EMS Documentation, Doct Ctrl, Operational Ctrl, Monit & Meas, Nonconformance & CA/PA, EMS Audit, Management

## Site Specific Records Schedule

- New BNL Records Schedule Issued
- Can be accessed through:
- http://www.isd.bnl.gov/records/
- SBMS Subject Area on Records Management
- Demonstration on EMS related records
- If you are unable to locate a specific records series title, please send an e-mail to Records Management so that they can include it in the next revision

## EMS Program Tasks 2001**

***Should be done: ***
- Review & revise Aspects spreadsheet.
- Establish FY 01 Objectives/Targets/Performance Measures & EM Programs (EMP form or equivalent)
- Verify adequacy of Operational Controls  (OCF or equivalent)

***Should be doing:***
-  Revising EMS Documents & verifying adequacy of document control
-  Tracking performance on Objectives/Targets & corrective actions
-  Reporting status & issues to management
-  Establishing EMS record series/schedules
-  Monitoring and implementing new/revised requirements

***Should be planning on doing:***
-  Training new employees, transfers, and visiting scientists
-  Communicating policy commitments to staff
-  Reinforcing use of Nonconformance/CA/PA systems
-  Scheduling EMS Audits & Management Reviews

***see slides from January and February meetings for more detail*

## Status of EMS ATS Actions

- RHIC Registration Audit – closed and verified by registrar
- August ’00 Registration Audit– closed
- Will be verified by registrar during 5/01 ORR
- August ’00 Self Declaration Audit – all items closed
- October ’00 Verification Audit-
- Five open items due 3/01-12/01 (ESHQ, CO, PE, EENS)
- NOTE:
- Objective Evidence of corrective action must be submitted to ATS (or directly to me) by 5/1/01
- Closure of corrective actions will be verified by registrar 5/9/01
- meeting between affected Reps with auditor will be scheduled during ORR for any Q&A’s

## Other Issues & Announcements

- New or Revised Subject Areas
- Hazard Analysis
- provides a "hazard screening“ process, which is applied to facilities and proposed modifications according to the magnitude of their hazards, to determine the need for and extent of follow-on safety analysis.
- Based on the technical safety analysis, identifies controls and/or safety limits that need to be included in the FUA which then becomes the authorization basis for the facility.
- Calibration
- Clarifies roles/resp for offsite suppliers of calibration services, onsite suppliers of calibration services, and calibrations done by Dept/Div staff
- Eliminates some forms and references to legacy documents
- Incorporated graded approach for identifying equipment requiring calibration, and incorporated ISO guidelines

## Next Meetings

- Next EMS Meeting  4/12/01
- 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*
- Next EMS Meeting Topics:
- EMS Implementation
- Progress on streamlining efforts
- Preparation for ORR
- Workshop on EMS Auditing, 3/15/01, Berkner B, 2:00
- Lab-level Management Review, 4/4/01 9:30 am, 490 CR