# Presentation: 101145

## Environmental Management System Project

**Lessons Learned **
**in EMS Assessments**
- Susan LK Briggs
- Roy H Lebel
- Ed Sierra & Joyce Mortimer
- Presented to BNL EMS Auditors, 3/15/01

## Why are we here?

- 78 EMS Audits conducted 8/98 – 2/01
- X internal self assessments
- X internal independent assessments
- X external assessments
- Provides rich source of experiences for continual improvement
- Share lessons learned
- what went well, what didn’t go well
- clarify areas where weaknesses were noted
- provide targeted refresher training on auditing techniques
- Strengthen and improve EMS Auditing process at BNL

## Agenda

- Lessons Learned from EMS Assessments
- Environmental Assessment Subject Area
- Highlights of Revisions
- New Checklists
- Generic Assessment Techniques
- Assessment Tracking System

## BNL Assessment Strengths

- BNL had an existing program already
- Tier 1, Tier 2, Tier 3
- Environmental Assessment program requirements well defined
- Accredited Training Programs conducted
- Large pool of trained auditors
- Resource sharing among organizations
- Independent views of conformance
- Management support of assessment results
- Timely closure of corrective actions
- Good preparation for registration audits

## Registrar Nonconformances

*Basis for EMS audit schedule did not reflect the ISO requirements: (1) results of previous audits and (2) environmental importance of the activity*
- Documented in Dir/Dept/Div EMS Manual and procedures
- Self Assessment Plan is the schedule
- EMS Project Schedule introduced constraints to implementation per requirement
**Need to verify practice is being implemented as described**
- Does schedule show different frequencies, or just “annually”?
- Are there mechanisms for changing schedule (ie., Ad hoc surveillance capability)
- Actual assessment dates
_*All *_*17 elements had not been audited*
- Elements were not sufficiently developed to assess
- Potential exists when operations, special circumstances preclude completion of original audit scope
**Need to document in report so follow-up can occur**

## Registrar Nonconformances

*Audit Checklist does not include space to record objective evidence nor are assessors using the form to record conformance*
- Checklists did not include the description of objective evidence reviewed or areas of conformance, only areas of nonconformance.
- Include document/procedure titles that demonstrate conformance
- Include specific reference to item that demonstrates nonconformance
- “Calibration was overdue on flowmeter used in {Bldg X, rm Y, operation Z }”
- “Comments” column intended for this purpose, but not used
- Checklist was not completed for each audit criteria
**Do not leave items blank; include notation in comments column (ie., not applicable, not assessed, objective evidence of conformance & nonconformance)**

## Registrar Nonconformances

*Employee awareness was not evaluated during audit*
***Need to verify worker knowledge of policy commitments***
*Open finding not tracked to closure*
*No closure documentation; item not actively being tracked*
*Mgmt Review Minutes incomplete:*
**did not** document evaluation of “EMS suitability, adequacy, & effectiveness”
**did not** document  that revisions to objectives & other EMS elements were evaluated
**Minutes must document in summary form issues discussed, recommendations made during discussions (for follow up) and sr mgmt evaluation. (include presentation material as attachment)**

##  Trends from Environmental Assessments

**Variability in the quality of audits and audit reports and forms used. **
- Thoroughness and focus varied
- Done at the time when “facility-specific” assessment checklists were being tested
- Checklists were not always used
- If not used, onus is on auditor to describe in report audit scope, critieria and their findings with respect to each criteria
- If checklist is used, report can summarize audit findings (defering to checklist for additional detail)
**Findings did not provide sufficient detail **
- Owners experienced difficulty determining what the problem was
- Were not linked to specific ISO 14001 requirements.
- Recommend stating nonconformance in terms of ISO requirement, and adding descriptive text that puts it within context (on checklist or in report)

##  Trends from Environmental Assessments

**Variability in the classification of findings**
- Awareness & alignment with registrars terms is prudent
**Major nonconformance** – Absence or complete breakdown of an EMS element.
**Minor Nonconformance** – Single observed nonconformance
**Observation** – determined to be insignificant or not a nonconformity
**Opportunity for Improvement** –a quality improvement
- BNL has multiple drivers, therefore use BNL classification system
- Refer to presentation on Consistent Auditing
- Make recognition of positive noteworthy practices!
- My opinion: Avoid recommendations unless requested by client
- Workers are most qualified to know how to fix a problem
- Ownership of actions is jeopardized
- If given, at least segregate in the report as an attachment

## Examples

- “Inconsistencies between ESR & OCF information”- Minor NC
- “Recommend inclusion of suppliers & subcontractors in training efforts” – Major NC
- “EMP forms did not have clear objectives” – Major NC
- “Regarding XX tank, implementation of required operational controls not evident” – Minor NC, noncompliance; could be major if systemic
- “It is not clear when the supervisor notifies the EMS rep of a change, who actually makes sure the aspects get reviewed” – Observation
- “Inspection procedure was dated 1991, & no evidence of review/revision”- Minor
- “The PEP Subject area requires an annual evaluation  & update” - ?
- “According to self assessments, some evaluations are scheduled for lower hazard processes” - ?

##  Trends from Environmental Assessments

**Records requested/needed to demonstrate conformance to ISO 14000 requirements were not produced during audit**
- Remain vigilant & followup, but defer to EMS Rep for assistance if staff are not responsive

## Improvement Opportunities 

- Organizations with major significant aspects (e.g., C-AD, F&O) should include staff with environmental expertise on the audit team.
- Consider establishing a small core of well trained, effective ISO 14001 auditors to lead audits as a purchased service.
- Have auditor review corrective action plans
- Consider tracking corrective actions for _observations, opportunities for improvement_ _and recommendations_.
- Create a central repository for EMS self-assessments and management review documents

## Improvement Opportunities 

- Facilitate followup and trending of EMS Findings
- Use ATS to track EMS self-assessments
- Use keywords (EMS, ISO 14001) in ATS “action reports”
- Use the ATS “external/internal reference” to crossreference audit finding numbers to actions
- Use ISO element name in ATS “action title”
- “Operational Control”
- Include sufficient description of objective evidence of closure in ATS closure report
- Good audit provides summary of the audit, who was involved, who interviewed (if applicable), findings & noteworthy practices
- Tool for managers to assess “state of program” & direct further improvements
- Provide programmatic perspective - differentiate between what’s important and what’s a nit

## Related Recommendations

- Schedule an audit of  EMS Assessments/IAP Implementation
- Verify documents address Schedule/frequency, resources, responsibility, reporting/tracking results
- More consistent and clear guidance on the content and structure of self-assessment plans would be helpful.
- Develop a Subject Area for handling external audits to help line and support organizations achieve consistency on notification, participation, documentation, closeout meetings, etc.
- Line organizations should ensure that audit findings are closed out in a timely manner and that documentation is available to external auditors.
- Follow-up with EPA on corrective actions taken in response to Year 3 audit.

## Obstacles Expected

- Since the EMS is not a standalone system, it is difficult to evaluate it without evaluating other related management systems
- In the midst of so many external audits, it is difficult to conduct internal audits
- Drain on the line organizations resources
- Self audits are required by ISO
- Future benefits expected in terms of reduced oversight
- The NSF-ISR audit report documentation packages were massive, organized by phase, and difficult to locate the final conclusions.
- Difficult to link audit finding to ISO clause
- Especially when nonconformance is related to internal procedure
**Vigilance to overcome these challenges**

## Corrective Actions To-date

- Organizational EMS Documentation has been reviewed and revised
- However, need to verify that the practice is being implemented as described (and required)
- Environmental Assessment Subject Area and checklists were revised
- Reduce number of options for judging level of conformance
- New checklist that includes prompts or questions to help auditors.
- Family ATS created for use by organizations
- Lessons Learned Workshop conducted
- To ensure that audits are conducted in accordance with the BNL procedures, particularly Planning, conducting, and documenting

## Environmental Assessments Subject Area Revisions

- 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

## Exercises & Reference Material

- Exercise: Case Study - Identifying and classifying ISO nonconformances
- ISO 14001“SHALLS”
- List of requirements
- List of site-specific documents
- Index/Cross-reference
- Excerpt from ISO 14001 Standard
- Example Audit Report

## Summary

- Environmental Assessing is a **well developed program** at BNL
- EMS Assessments have successfully prepared BNL for **ISO registration**
- These efforts are to take Environmental Assessments to the next level
**Continual Improvement! **