Design-Guidance-Workbook ISO 14001
Design-Guidance-Workbook ISO 14001
Design-Guidance-Workbook ISO 14001
Version 2.2
June 2020
Table of Contents
Introduction
Timeline
Summary of EMS Team Meetings
Management support, Context, Scope, Roles & Responsibilities, Initial Training
Step 1 -
(4.1, 4.2, 4.3, 4.4, 5.1, 5.3, 7.2)
Step 1a - Context of the Organization - Food for Thought
Step 1b - Context of the Organization - Form
Step 1c - Identifying Interested Parties - Form
Step 1d - Assigning EMS Roles and Responsibilities - Form
Step 1e - Registrar Selection Considerations
Initial Environmental Review, Identify Compliance Obligations (6.1.3) and
Step 2 –
Evaluation of Compliance (9.1.2)
Step 2a - Initial Environmental Review - Form
Step 2b - Compliance Obligation Review - Form
Step 2c - Compliance Obligation Review - Form - Example
Step 3 – Policy, Environmental Aspects and Impacts Analysis (5.2, 6.1.2)
Step 3a - Environmental Aspects & Impacts - Summary Form
Step 3b - Environmental Aspects Ranking Criteria - Form
Step 3c - Environmental Aspects & Impacts - Form
Step 3d - Life Cycle Perspective - Food for Thought
Step 4 – Operational Control and Emergency Preparedness and Response (8.1 & 8.2)
Step 4a - Operational Controls - Form
Step 4b - New Projects Checklist - Form
Step 4c - Control of Outsourced Processes - Form
Step 4d - Organization's Environmental Requirements and Communication - Form
Step 4e - Emergency Preparedness and Response - Form
Step 5 – Monitoring and Measurement (9.1.1)
Step 5a - Monitoring, Measurement, Analysis and Evaluation - Form
Step 6 – Environmental Objectives (6.2.1)
Step 6a - Environmental Objective - Form
Step 7 – Documentation and Document Control - Section (7.5)
Step 7a - EMS Document Control - Form
Step 7b - Documentation Control - Procedure - Example
Step 8 – Competence and Awareness (7.2 and 7.3)
Step 8a - Training Needs Matrix - Form
Step 8b - Training Record and Competency Sign-off - Form
Step 9 – Nonconformity and Corrective Action (10.2)
Step 9a - Corrective and Preventive Action Request (CPAR) - Form
Step 9b - Environmental Corrective Action Request Log - Form
Version 2.2, 6/20
Table of Contents Page 2 of 97
ISO 14001:2015 Environmental Management System
Design Guidance and Timeline
Step 10 – Communication, Management Review and Improvement (7.4, 9.3, 10.1, 10.3)
Step 10a - Examples of External EMS Communication from ESI Stewards
Step 10b - Management Review Minutes - Form
Step 11 – Internal Auditing (9.2.2)
Step 11a - Audit Checklist - Form
Step 11b - Nonconformity Report - Form
The Division of Environmental Assistance and Customer Service (DEACS) developed the following EMS
guidance materials and timeline to provide ESI participants with an organized approach to EMS
development. The tool covers the majority of EMS elements but may not address every requirement in
ISO 14001:2015. An organization should use ISO 14001:2015 as its main reference document for EMS
design and implementation. This guidance and timeline have been organized in order to assist facilities
to:
The EMS team is comprised of individuals from a cross-section of the organization with broad knowledge
of facility operations. The Environmental Management Representative serves as the EMS “champion” and
may work alone or with one or two other individuals to set meetings, complete unassigned tasks and
keep the process moving between team meetings.
In addition, six modules have been developed to provide training on specific EMS elements. Modules
align with steps outlined in this guide and are designed to be used in conjunction with it. The six
modules are:
Module 1 EMS 101: Introduction to EMS and ISO 14001:2015, Context & Scope
Module 2 Aspect and Impact Identification and Ranking
Module 3 Operational Control and Monitoring & Measurement
Module 4 Establishing Objectives, Document Control, & Training
Module 5 Corrective Action, EMS Auditing, & Management Review
Module 6 EMS Internal Auditor Training
Contact DEACS, 1-877-623-6748 or esi@ncdenr.gov for more information on module training classes.
Month 10
Month 11
Month 12
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
EMS Elements
Example forms and procedures for all elements can be found here:
https://deq.nc.gov/about/divisions/environmental-assistance-customer-service/environmental-stewardship-
initiative/environmental-management-systems
Mgmt Meeting
Team Meeting
Week
Module Activities
Mgmt Meeting
Team Meeting
Week
Module Activities
In this the initial step of developing your EMS we will cover a number of topics and develop EMS
procedures and records that will lay the groundwork for the other elements described in the later steps in
this guidance. Step 1 is scheduled as three separate management meetings to complete all work and kick
off your EMS implementation. You are welcome to adjust this schedule as it relates to your organization.
Scheduling:
Management Meeting 1 - Complete the Commitment and Context portions of Step 1 (Items I and II)
Management Meeting 2 - Complete the Interested Parties and Scope portions of Step 1 (Items III and
IV)
Management Meeting 3 - Complete the EMS Resources, Organizational Structure and Roles and
Responsibilities, Training Needs portions of Step 1 (Items V to VII)
Allow two to three weeks between the three noted meetings; adjust schedule as needed
You may want to schedule the EMS kickoff meeting in conjunction with the final meeting; tailor this rollout
to your needs.
The following graphic describes the general steps to successfully develop and implement an environmental
management system.
The “Getting Started” flow chart is based on a similar chart from Environmental Management Systems: An
Implementation Guide for Small and Medium Sized Organizations , NSF International, 2001
Therefore, top management and those assigned to implement the EMS should review how they
can demonstrate the organization and its leaders have met these requirements.
Initial steps may include a kick-off meeting with EMS team members and top management as this
demonstrates commitment, support, and interest in EMS efforts. The meeting could review all
items noted in Step 1 of this design guidance. A letter to EMS team members from top
management may also show support for EMS efforts.
What are other ways for leadership to demonstrate support in your organization?
No organization operates within a bubble so in a holistic approach the organization is tasked with
understanding the issues that can affect its ability to achieve the intended outcomes desired by
implementing an EMS.
Items to be considered:
- Determine the environmental conditions that can either affect or be affected by the
organization
- Determine external issues that may affect the organization’s ability to improve (e.g. legal,
economic, social, or political)
- Determine internal characteristics and their role in the organization's context such as work
force, knowledge, processes, systems, finances, corporate requirements, etc.
P lease be aw are that the 2015 standard requires that you consider the context of the
organization when developing the scope of the EMS (Step 1) and that the environmental policy
(Step 3) and objectives (Step 6) be compatible with the context of the organization. It also
requires that you consider your organizational context when planning for the EMS and
identifying risks and opportunities to the organization and the EMS.
Here is an example loosely based on a blog discussion from the 14001 Academy on
organizational context to wrap our minds around this concept.
Let’s say our organization is a food manufacturer for a popular snack product, so what could we
consider when developing our organizational context? One of our key production components
is our supply of wheat.
Environmental considerations:
- Transportation issues associated with wheat delivery
- Air quality issues with wheat storage
- Water issues (runoff contamination) from wheat storage and processing
- Effects of climate change on wheat supply
- Adverse environmental impacts from wheat production in agricultural communities
- Can you think of any other environmental issues?
External considerations:
- Negative publicity from environmental issues may lead to a drop in share price
- Opportunities may arise from sourcing wheat from another area of the world
- The perceived issue of gluten sensitivity may affect sales
- Congress may pass new labeling requirement legislation for different genetic strains of wheat
- Can you think of any other external issues?
Internal considerations:
- Employee language barriers may affect adherence to procedures and environmental
compliance
- Corporate finance requires a 10% budget reduction in wheat purchases
- Needed equipment replacement may reduce production
- Can you think of any other internal issues?
The life cycle stages are noted in section 3.3.3 as acquisition of raw materials, design, production,
transportation/delivery, use, end-of-life treatment and final disposal. Taking this holistic view of
the organization and its processes may help you develop a robust context of your organization.
As noted above it will be used in developing other sections of your EMS.
Action:
Step 1a contains a summary of items to consider when trying to identify the context of your
organization. You may want to review it and have it handy when completing the worksheet in
Step 1b to develop the context of your organization.
Management Meeting 2 - complete Items III and IV
Section 3.1.6 defines an interested party as a person or organization that can affect, be affected
by, or perceive itself to be affected by a decision or activity (must be made known to the
organization). Stakeholder review can be a high-level review of internal and external parties.
Examples of other requirements that become compliance obligations include industry standards,
contractual relationships, codes of practice and agreements with community groups or non-
governmental organizations.
As a member of the DEQ Environmental Stewardship Initiative there are compliance obligations
related to annual reporting that should be included in your EMS.
Action:
Complete the worksheet in Step 1c to determine the interested parties for your organization and
its EMS. You should review your organization's context to help identify interested parties and
also gather any external complaints that have been received. There is space allotted on the
worksheet to note which interested parties have compliance obligations linked to them. This
review will give you a basis for identifying compliance obligations completed under Step 2 of the
guidance.
IV) Determine the Scope of the EMS (4.3)
The organization must determine the “scope” of the EMS. The scope defines what part of the
facility or organization will be covered by the EMS and what will not (clarifies any physical and
organizational boundaries). For example, are you including all functional groups or just a subset.
The organization must maintain the scope as documented information (see Step 7) and
supply it to interested parties (Step 10).
Although the EMS scope is determined during this initial step, an organization may continue to
revise it later in the EMS development or over time through continual improvement. Please
remember that the scope influences every other part of the EMS as it defines what’s included
within it.
Action:
Write a description of the EMS scope for your organization. Can you think of any areas that
should not be included?
Management Meeting 3 - Complete Items V to VII. You may want to schedule facility EMS kick-off
meeting to coincide with this meeting or directly following it. EMR to complete Step VIII if needed in
parallel to other tasks in Step 1.
- Therefore, the organization may want to develop a draft budget for the EMS. Costs
related to the EMS could include development, implementation (signage/postings), external
training, travel, consultants, software, external auditors, and registration.
VI) Review organizational structure and select initial roles and responsibilities (5.3)
For an ISO 14001 EMS top management must ensure that key roles and responsibilities are
assigned and communicated within the organization.
Please Note: In previous versions of this standard these responsibilities were assigned to a
staff member known as the EMR (Environmental Management Representative). This terminology
will continue to be used in the design guide.
Action:
Use the worksheet in Step 1d to develop the roles and responsibilities for the organization's EMS.
The EMR or person(s) within the organization that has been assigned these responsibilities
should:
- Determine if the organization will use an EMS software program or consultant
- Organize an EMS team who will assist in the design and implementation of the EMS. This team
should include representatives from a cross-section of the organization that are knowledgeable
of facility operations. The team needs to represent all key areas and be comprised of decision-
makers for each area to facilitate timely EMS implementation.
- Set team meetings and track team progress
- Plan for integration with a quality management system or health and safety management
system such as ISO 9001, 50001, or OHSAS 18000.
- Develop an implementation schedule including reports to top management on progress of EMS
design and implementation. Set a target date for certification or self-certification and work
backwards from the date.
- Develop a kick-off meeting or memo to all staff regarding the implementation project.
- Upon implementation of the EMS, assure the ongoing scheduling and reporting on the EMS at
management review meetings; ensure the corrective and preventive action process is
functioning; assure completion of internal and external EMS audits and internal compliance
audits; and arrange ongoing training of all employees about the EMS policy and EMS
awareness.
Suggested actions:
The organization may want to consider assigning a management representative for each
organizational unit (i.e. sections, departments, etc.) who will:
- Participate as a member of the EMS team
- Assure the EMS is maintained and resources allocated
- Report to top management or top management representative on the performance of the
EMS at defined intervals once the EMS is implemented (9.3 Management Review)
Another useful designation to make early is a document/record controller(s) who will:
- Ensure that all controlled documents and environmental records are maintained according to
the EMS documented information control requirements (7.5 Documented Information) once
these procedures are established internally. Often, the document/record controller and the
EMR are the same person.
VII) Identify external training needs for key personnel (7.2)
The organization will be required to identify the necessary competence needs and training
requirements related to the EMS as noted in Section 7.2 of the standard. This requirement will be
covered by Step 8 of the Design Guide but it is useful at this step to identify training and
competence needs for top management and staff assigned to implement the EMS. As decisions
are made regarding competence of this personnel ensure that you document it using the tools
you develop in Step 8 of the Design Guidance.
- Lead auditor training, internal auditing training, or at minimum an introductory ISO 14001
course is strongly recommended for the EMR. Even if this person is not involved in auditing,
the training provides an understanding of the process and audit reports.
- Identify mentor organizations whose EMR can provide guidance during design and
implementation. ESI staff can connect you with an appropriate organization within the
program that can serve as a resource.
- The top management representative within the organization (e.g. plant manager) should
attend training on the intent and structure of the ISO 14001 standard and environmental
management systems or have discussions with top management of mentor organization(s) on
the EMS process and the resources needed for successful implementation, maintenance,
continual improvement.
- EMR and key personnel should consider attending an internal or third-party EMS audit of a
mentor organization.
- The ESI program provides EMS training based on member organization interest. You can view
training options and upcoming training on the ESI website at
http://deq.nc.gov/about/divisions/environmental-assistance-customer-service/environmental-
stewardship-initiative/training. You are also welcome to contact one of the ESI program
managers by sending an e-mail to esi@ncdenr.gov to discuss your particular needs.
- Consider registrar attributes prior to selection of a registrar. This may include experience, fees,
surveillance schedule, what they expect to see for documented procedures, how non-
compliance is handled, etc. Step 1e contains information to consider when choosing a
registrar.
- A pre-registration audit or readiness review is highly recommended to identify any key issues
prior to the actual registration assessment.
The following sections contain some ideas to consider when developing your organizational context. By no means
is it meant to be all inclusive as only you can analyze and develop the context for your organization.
Environmental Considerations:
Examples can include climate (change), air quality, water quality, land use, existing contamination, natural
resource availability and biodiversity that can affect the organization's mission, be affected by its environmental
aspects, or can play a role in the life cycle of the organization's products and services.
Climate:
-Do large scale climate fluctuations/changes have an effect on your operations, raw materials, disposal options?
-Does local weather have an impact on production, services, facility equipment (e.g. temperature, humidity)? Is
the local area susceptible to drought, flooding, tornadoes, hurricanes?
-Is the facility located in a floodplain or within a noted FEMA flood zone? Consult http://www.ncfloodmaps.com/ if
needed.
-Does climate change pose an increased risk for insect infestations that would affect your operations.
Air Quality:
-Does the facility have process air emissions that are subject to regulation? Is a permit required, is registration
required, or are emissions exempted?
-Is facility located in a non-attainment area for a priority pollutant? Does this affect expansion?
-Are there power generation facilities on site? Are they regulated? Is permitting required?
-Is a Risk Management Plan required for use of extremely hazardous substances as noted under Section 112(r) of
the CAA?
-Could local ozone action days affect facility employees and required job functions? Is your organization located in
a non-attainment area?
-Is there equipment on site with Freon or other refrigerants that require special handling?
Water Quality/Use:
-Do local pretreatment/sewer use ordinances affect production/expansion?
-Will drought conditions necessitate installation of supply wells or require new wells be drilled?
-Do NPDES direct discharge permit limits affect production/expansion?
-Do you own sewer lines/pump stations on site? Are you aware of reporting requirements for sewer overflows or
inspection requirements for industrial pump stations?
-Is an industrial stormwater permit required and how does this affect operations?
-Are there any other local or state stormwater requirements (post-construction, HQW, ORW, coastal counties,
nutrient sensitive waters)?
-Is cooling water needed? Is the direct discharge to surface waters permitted?
-Would facility/organization be affected by salt-water intrusion (groundwater supply) or tidal issues?
-Could water availability/flow affect your operations?
-Does your region have a Riverkeeper or other active organization?
-Does your organization have common permits with other entities?
-Does saltwater intrusion pose a risk to your operations?
Land Use:
-Where is the facility located? Who are your neighbors; other industry, residential areas, schools, open space?
-Is the facility required to report under EPCRA for the storage or release of chemicals?
-How long has the facility existed? Is there residual contamination that needs to be managed?
-Are there underground storage tanks that need to be managed/regulated?
-Are there aboveground storage tanks or outdoor storage of totes and drums that fall under local fire codes or
under secondary containment requirements under industrial stormwater or SPCC requirements.
-Are TSCA regulated chemicals stored near drinking water sources (2016 update)?
-Does the facility's activities create noise, truck traffic, or other issues that may draw complaints?
-Are there transformers on site? Who owns them? What type of oil do they contain? Do they contain PCBs?
-Do insects or other pest infestations affect your production?
-Is part of your facility set aside for wildlife or wetland protection?
-Do you have any tenants onsite? How could their operations affect you and vise versa?
Natural Resources/Biodiversity:
-What natural resources are needed as raw materials?
-Is biodiversity/wildlife affected by material usage or final disposal?
-Are ample supplies of potable water and wastewater available? How do operations affect these supplies?
-What types of energy/fuel is used? Have you explored options to reduce energy usage?
-Do invasive species threaten your raw materials?
Transportation:
-What types of transportation are used in supplying raw materials, shipping finished products, or transporting
wastes off site?
-Is transportation supplied by the organization or is it contracted?
-How does transportation fit into our emergency management procedures/processes?
-What types of transportation are used to move intermediary/finished products within our facility?
Waste Generation:
-What types of wastes are produced?
-How are wastes disposed (landfill, incineration, land applied, beneficial reuse, etc.)?
-What is currently being recycled or reused?
-Are there corporate or other mandates for zero waste to landfill or waste minimization?
External Considerations:
Examples can include the cultural, social, political, legal, regulatory, financial, technological, economic, natural and
competitive circumstances that can be international, national, regional, or local in nature.
Legal:
-Do we have any legal requirements from legacy contamination?
-Do we have any legal requirements from historic/current waste disposal (e.g. Superfund)?
-Do we have any active litigation due to environmental considerations?
-Have we identified our legal obligations from emergency situations?
Regulatory:
-What the regulatory requirements associated with facility operations (air, water, waste, land)?
-What are the applicable federal, state, and local regulatory requirements from land or chemical use?
-Are we meeting our obligations? What is the cause of noncompliance?
-How do we stay up to date on regulations?
-Are there any issues with proximitiy to neighbors/community (noise, oder, dust, etc.)?
Financial:
-What are the financial constraints to implementing our EMS?
-How is our industry performing? Shrinking or expanding?
-How are the national and global markets performing?
Social:
-What is the public perception of our products/services?
-Can we improve our environmental reputation?
-What is our involvement in the community?
Economic:
-What is our competition doing?
-Is EMS being driven by a customer?
-Are our suppliers on board with meeting our requirements?
-Have we sourced additional suppliers/vendors based on cost?
Internal Considerations:
Examples include internal characteristics or conditions of the organization such as its activities, products and
services, strategic direction, culture and capabilities (i.e. people , knowledge, processes, systems).
Work Force:
-Are there language barriers that could affect our environmental performance?
-What are our training requirements and who will provide it?
-Will our culture support implementation of an EMS?
Corporate:
-What are the corporate requirements for environmental performance?
-Is there support for environmental initiatives?
-Are requirements being applied to sister sites that can assist with EMS?
-Are any new strategic initiatives on the horizon?
Knowledge:
-Is knowledge of operations broad-based or localized to a few key individuals?
-Is cross-training of staff needed for key job functions?
-Have processes been formally documented?
When choosing a registrar, you are starting a relationship that will last many years. You must make
careful decisions to lay the groundwork for a smooth and lasting relationship.
While all of the questions are important, the most important factor to consider is how well a registrar can
work with you. This includes how well they know your industry, experience with similar organizations and
how well they communicate with you (and your employees during an audit).
It is less expensive to use a local registrar that can drive rather than fly to your facility. However, do not
select a registrar on cost alone. Registration is an ongoing journey and your “comfort level” of working
with the registrar over time is most important.
You may want to inquiry with other ESI members and who their registrar is and what insight they may
have in choosing a registrar.
EMS Team Meeting 1 Objective: To assign responsibilities for collecting information for the initial
environmental review, which serves to identify the parts of an EMS already in place as well as collect
information for use in later steps. This information will be useful in addressing a number of EMS
elements. A more comprehensive job done now will ease work later. Develop process for periodic
evaluation of compliance.
Use the Initial Environmental Review Table in Step 2a to assign responsibilities for
collecting information.
Complete the Compliance Obligation Review Table in Step 2b. See example in Step 2c.
III) Determine how the organization will keep current with changing or new regulations
and compliance obligations.
- There are many ways to do this including but not limited to:
- subscribing to a service,
- getting updates from industrial trade groups,
- attending trainings,
- checking regulatory websites,
- joining regulatory list serve,
- contacting a DEACS environmental assistance coordinator,
- hiring a consultant,
- contacting NCSU IES or
- referring to corporate legal team.
Write the procedure for determining compliance obligations and evaluation, see example
procedure EP-02 Compliance Obligation and Evaluation. This procedure must be
maintained as documented information.
Environmental
Aspects
(Do NOT fill
General out, this column Summary of Location of
Reg. Description of will prepopulate Controls (SOPs, Guidance Date Due and Documents &
Compliance Agency / Citation Compliance Applicability from the info in Plans, Permits, Documents & Monitoring Frequency of Records Required
Obligation Driver & Link Obligation Trigger Step 3) etc.) Resources Requirements Reporting to be Maintained
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 0
10 0
11 0
12 0
13 0
14 0
15 0
16 0
17 0
18 0
19 0
20 0
Keep Qualitative
Permit Qualitative
NPDES Monitoring
SDO (Storm required if monitoring:
Industrial records, Non-SW
water outfall facility: is twice a year,
Stormwater Discharge Certs,
discharge) manufacturin Qualitative Non
Permit, SOP of SW Pollution
monitoring, g SIC, has a SOPs and monitoring, stormwater
Visual Prevention Plan,
SW Pollution point source guidance Non discharge cert:
Stormwater NC DEQ 40 CFR Stormwater Inspections, Copies of
Prevention Plan, discharge, documents stormwater once a year,
Permit DWR 122.26 runoff SOP of How to Sampling Results,
Maintain Storm stores or located in discharge Sampling: twice
Sample Calibration and
water BMP processes main office certification, a year unless
Stormwater, maintenance
(Best materials Sampling above
Non-Stormwater records for five
Management outside benchmarks
Discharge years. Submit
Practices) (exposed to then once a
Certification sampling results
storm water) month
within 30 days
Develop and
Internal and
Implement and SOPs and All monitoring Recertification
External
ISO EMS which All guidance requirements every three All records
Custome Environmenta Auditing of the
EMS 14001:2 meets Environmental documents associated with years, Internal associated with
r Driver l Aspects EMS, all SOPs
015 requirements Aspects located in Environmental audits every the EMS
associated with
for ISO 14001 main office Aspects year.
the EMS
certification
Team Meeting 2: Review environmental information to develop team’s knowledge and awareness of
issues. Draft environmental policy. Assign responsibilities for the identification of activities, products and
services within the EMS scope and associated aspects and impacts and meet in three weeks.
Environmental policy helps guide setting significance criteria and setting objectives and targets. Some
facilities choose to begin EMS design with creating a policy statement. Top management must establish,
implement, and maintain an environmental policy that:
- Must include the three major commitments:
1) continual improvement,
2) protection of the environment including prevention of pollution, and
3) to fulfill its compliance obligations.
- Must be documented, available to interested parties, and communicated to all employees and to those
working on behalf of the organization.
The environmental team may draft this policy and as appropriate, circulate for input and feedback as long
as top management is fully invested in the product.
Example:
II) Establish a process to address risks and opportunities (aspects) (6.1.1 & 6.1.2)
The standard requires that an organization establish, implement, and maintain a process for determining
and addressing its environmental risks and opportunities related to its environmental aspects, compliance
obligations, and other issues and requirements identified during its review of context, needs and
expectations of interested parties, and definition of scope. This review is addressed in Step 1 of this
guidance. See worksheet Step 1b.
An environmental aspect is related to an organization’s activities, products, and services and can interact
with the environment. Aspects may or may not be regulated. An environmental impact is any change to
the environment, whether adverse or beneficial, wholly or partially resulting from an aspect. When
determining aspects, the organization must:
Documentation is required for the risks and opportunities that need to be addressed and the processes
necessary to make sure they are making progress as planned. As you develop your aspect and impact list
also document the risks and/or opportunities for each aspect or impact listed. These are potential adverse
effects (aka threats) and beneficial effects (opportunities). An example of risk would be failure to comply
which can have the effect of legal action and/or damage to reputation in addition to any environmental
impact. Similarly, an example opportunity of going beyond compliance would enhance the organization's
reputation.
Aspect and impact lists may be developed through EMS team brainstorming or team members might
collect information with input from other personnel. Be sure to include all areas covered by the EMS scope.
- List activities, products and services within the EMS scope over which the organization
has control or influence. Refer to existing flow charts or process flow diagrams. Refer to
the Initial Environmental Review performed in Step 2.
- List associated actual and potential aspects and impacts for each activity, product and service. You
might use the form in Step 3a to capture this information. An aspect may have more than one
environmental impact. Make sure to list positive environmental impacts as well as the negative.
Consider listing any observations, such as related management controls, along with each aspect to
assist with later review.
- Include aspects and impacts from normal and abnormal operating conditions including start-up, clean-
up, maintenance, planned shutdowns, emergency situations and foul weather.
- Include aspects and impacts from planned or new developments, new or modified activities (i.e.
construction), products and services.
Team Meeting 3: Review listing of aspects and impacts. Develop ranking criteria and rank each aspect
and related impact to determine significance. Meet in three weeks to finalize ranking list.
- Review listing of aspects and impacts. Consider grouping similar aspects. However, an
organization may keep aspects listed separately that have different impact levels. For example
“water use” may be an aspect across the facility or listed as separate aspects in specific
departments to account for greater use in certain areas.
- Write process summary to identify aspects and impacts.
- Determine whether to use quantitative or qualitative ranking criteria (or a combination) and
develop associated definitions. Facility may consider weighting specific criteria relative to others.
The 2015 version of the standard leans heavily toward the use of a qualitative ranking system as
the criteria for ranking is required to be documented.
- Consider using a limited number of criteria to gain experience and confidence without being
overly complex. Consider using a limited scoring range, at least initially, for easier use and
understanding. Make sure aspects with positive impacts can be determined significant.
- Develop definitions for each criteria used to determine significance. For instance, in a category of
“probability” define high, medium and low.
- Apply criteria to rank aspects. Assess need for any modifications. Ranking system should be
repeatable for future aspect listings.
Only a facility’s staff can determ ine how to assess significance. I t is im perative that the
process is docum ented and replicable.
- Below are some examples of criteria and ranking that may be used or modified. Upon deciding
on the criteria that will be used be sure to document this. You may use the table in Step 3b to
capture this.
Regulatory Visibility
Identifies whether an impact is associated with government requirements and how "volatile" the issue may
be
Regulated - mandated by a federal, state, or local government agency. Issue will be on the
5 "regulatory radar screen (will be reviewed). Examples are Air, Water and Hazardous Waste
Issues (Permitted Issues). ALSO some OSHA issues are very visible
Regulated - mandated by a federal, state, or local government agency. But issue is not really on
4 the "regulatory radar screen (will not be reviewed unless community or employee reports them
(whistle blower). Things like SPCC plans, TSCA issues, EPCRA, Ozone Depletion, etc.)
Regulated Indirectly or with very few requirements. Examples of this would be Solid Waste
3
requirements (have a container and use licensed landfill)
2 Unregulated presently, but maybe regulated in the future
1 Unregulated - no guidance.
Severity
The degree to which surroundings (including air, water, land, natural resources, flora, fauna, and humans)
are affected by an impact. This criteria incorporates toxicity of the pollutant and size or scale of release.
5 Severe/catastrophic - very harmful or potentially fatal; great effort to correct and recover.
4 Serious - harmful but not potentially fatal, difficult to correct but recoverable.
3 Moderate - somewhat harmful, correctable.
2 Mild - little potential for harm, easily correctable.
1 Harmless - no potential for harm, correctable.
Probability
An indicator of probability. Attempts to rate impacts on the probability of their occurrence.
5 Very likely - high probability (90% or more) that an aspect will result in a detectable impact.
4 Likely - strong probability (68% to 89%) that an aspect will result in a detectable impact.
3 Moderate - reasonable probability (34% to 67%) that an aspect will result in a detectable impact.
2 Low - low probability (11% to 33%) that an aspect will result in a detectable impact.
1 Remote - very unlikely (10% or less) that an aspect will result in a detectable impact.
Frequency
How often an impact could occur. If it is very likely that an impact will occur, how often is it likely to
happen - daily, monthly, or once a year?
5 Continuous - occurs three times per week (on average) or more often.
4 Repeated - occurs one to two times per week (on average).
3 Regular - occurs monthly (on average).
2 Intermittent - occurs quarterly (on average).
1 Seldom - occurs two times per year (on average) or less often.
Boundaries
Geographic boundaries that reflect the physical area in which the impact occurs.
5 Global - impact migrates outside the region in which is located.
4 Regional - impact migrates outside local community in which is located.
3 Local - impact migrates off-site into surrounding community.
2 Confined - impact migrates off-site, but is contained in small, adjacent area.
1 Isolated - impact is contained on ' site with no migration.
Magnitude
Relative size of the impact. Incorporates frequency, duration, and load.
5 Very Large release of pollutants, resources used, etc.
4 Large release of pollutants, resources used, etc
3 Moderate release of pollutants, resources used, etc
2 Small release of pollutants, resources used, etc
1 Little or no release of pollutants, resources used, etc
Controllability
A key concept because ISO 14001 refers explicitly to the environmental aspects of a company's activities
that it can control and influence.
5 Directly controllable - controls processes and materials, no requirements imposed by customers.
4 Indirectly controllable - controls supplier contract, mandates use of materials and/or processes.
3 Influenceable - processes and materials controlled by customer or supplier.
2 Indirectly influenceable - processes and materials controlled by independent third party.
1 Uncontrollable - process and materials are not controlled.
Employee's Concerns
How important is this impact - to the employees
5 Primary concern to all/most employees
4 Primary concern to a few/one employees
3 Secondary concern to all/most employees
2 Secondary concern to a few/one employees
1 Little/no concern to employees
Reportability
This refers to any governing bodies that must be notified about the impact in question. May be more
applicable to impacts that result from abnormal operating conditions or emergency incidents.
5 Government authorities - reporting to federal, state, or local authorities.
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Step 3 Page 39 of 97
ISO 14001:2015 Environmental Management System
Design Guidance and Timeline
Corporate management - reporting outside the facility responsible for impact and its immediate
4
company to the corporate owner.
Company management - reporting outside the facility responsible for the impact, but with the
3
immediate company.
2 Facility management - reporting within the facility responsible for the impact.
Not reportable - no reporting required beyond documented procedure for monitoring and
1
measuring key characteristics.
Stakeholder Concerns
Reflects how external interested parties, typically defined in terms of customers, regulators, residents in
proximity to , and special interest groups, perceive an environmental impact.
5 Primary concern to all/most interested parties.
4 Primary concern to a few/one interested parties.
3 Secondary concern to all/most interested parties.
2 Secondary concern to a few/one interested parties.
1 Little/no concern to interested parties.
Duration
Pertains to the length of time that the environmental impact will be felt by affected parties.
5 Irreversible - controllable but not correctable.
4 Three years or more - great effort to correct and recover.
3 One to three years - difficult to correct but recoverable.
2 Three to twelve months - correctable.
1 Short-term - impact can be corrected in three months or less.
Business
If this impact has a high opportunity for improvement without high costs and without other business
disrupting considerations
5 High OFI, Low Costs
4 High OFI, High Costs
3 Low OFI, Low Costs
2 Low OFI, High Costs
1 No OFI
Regulated
Identifies whether an impact is associated with government requirements. Also includes self-imposed
requirements and any requirements described as "other" in ISO 14001 sections 4.2 and 4.3.2.
5 Regulated - mandated by a federal, state, or local government agency.
Regulated in future - not currently mandated by a government agency, but has a potential to
4
become regulated.
Company policy - industry standard, code of practice, or other initiative adopted and formalized in
3
company-wide policy.
Company practice - industry standard, code of practice, or other initiative that guides established
2
practice, but not formally codified.
1 Unregulated - no guidance.
Evaluate all Aspects identified across the entire life cycle of the product. Also, consider each
stage of the life cycle that the organization has any influence or control and determine if
additional aspects need to be added. Step 3d gives some ideas to consider when
-
determining additional aspects for each stage of the life cycle. To demonstrate that life cycle
perspectived has been considered, documentation in meeting minutes or the use of a table
similar to the below or within Step 3c can be used.
Depending on your specific process/product, Life cycle stages may include:
Design Transportation/Delivery
Acquisition of raw Use
materials End-of-life treatment
Production Final Disposal
Final Disposal
raw materials
Acquisition of
Production
End-of-life
treatment
Design
elivery
Aspect
Use
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Team Meeting 4: Review and finalize ranking of aspects and impacts. Determine significant aspects. Set
next meeting date for following week.
The results of using the ranking system should reflect the facility’s greatest environmental
-
concerns.
Review prioritized list for a “reality check” and finalize ranking. Determine which aspects are
- significant such as where the “cut-off” point will be or if an aspect scores high in any one
category, it is deemed significant.
- Determine significant aspects. The list of significant aspects will be used in:
* setting objectives and targets;
developing operating procedures related to activities that have the potential to result in
*
significant environmental impacts and those related to identified significant aspects;
* assuring proper training and competence of appropriate individuals; and
development of key monitoring and measuring characteristics related to these actual or
*
potential impacts.
Combine all data from Step 3 into a single Aspects and Impacts document similar to the form provided in
Step 3c.
Write procedure for determining aspects and impacts and significance ranking. See example
procedure EP-01. This procedure must be maintained as documented information.
Significant Aspects must be communicated to all appropriate employees. See Step 10 for Communications.
Activity,
Compliance
Product or Aspect Impact Risk Opportunity
Obligation
Service
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Transportation/
Final Disposal
Acquisition of
raw materials
Production
End-of-life
treatment
Delivery
Design
No. Aspect
Use
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Ranking
Significant (S)
Adequacy of
Impact or Potential
Risks & Opportunities General Comments
Impact
Controls
Current
TOTAL
The following sections contain some ideas to consider when developing your aspects and impacts. You'll notice as you go through
this process that these stages overlap each other and are not necessarily a linear process. By no means is this document meant
to be all inclusive as only you can analyze and develop the impact of your organization.
Design Considerations:
During the design phase, aspects can be affected through advanced planning. Some things that might be considered at this stage
are:
What raw materials are needed?
- Can renewable resources be used?
- Can the design reduce the need for Hazardous Materials by using 'green chemistry'?
- Can you use recycled content materials or increase the amount of recycled content?
- Can materials be sourced from local suppliers?
Production Considerations:
What products are made?
What materials are used?
What types of wastes and discharges are generated?
What type contractors, vendors, suppliers are on site?
What do you do off-site (deliveries, servicing?)
Where are you located?
What permits/regulations do you have?
What fuels or other energy sources are used? How much?
How is water used in the process? And how much?
What about wastewater?
Transportation/Delivery Considerations:
What do you ship or receive? Look at products, raw materials, & wastes
Take into account air emissions including GHGs.
Take into account fuel usage and other maintenance needs.
How can you prepare for traffic accidents (Hazardous waste spills, parts damage, etc)?
How do you prepare for fluid leaks on your property (oil, hydraulics, etc.)?
How do you protect parts from damage due to shifting, poor packaging, corrosion, etc?
Include fork trucks and other internal transportation (emissions, damage from forks, fuel use, batteries, etc.)
Use Considerations:
How is the product used? Are there environmental impacts from the use?
- Energy use?
- Water use?
- Waste materials?
- Packaging?
EMS Team Meeting 5 Objective: To establish, implement, control and maintain the processes needed
to meet the EMS requirements and needed to implement the actions identified in Steps 2 and 3. To
establish controls for planned changes and response protocol for unplanned changes. To establish
controls for outsourced processes. To determine the organization's environmental requirements and
establish controls for the life cycle of the product or service, as appropriate. To consider the need to
provide information about potential significant environmental impacts associated with the transportation
or delivery, use, end-of-life treatment, and final disposal of the organizations products and services. To
establish, implement and maintain processes needed to prepare for and respond to potential emergency
situations.
- Assign responsibility for the development of operating critera/work instructions. Set time frame
for completing work instructions and procedures depending on volume.
- Determine how to ensure the implementation of the control process(es). It is not enough to
have an operating criteria, the organization must ensure that the control processes is being
implemented in accordence with the operating criteria.
- Determine what, if any, documentation is needed to have confidence that the control
process(es) has been carried out as planned.
See example "Operational Controls" table below
II) Identify existing and needed forms and checklists associated with work instructions
- Forms and checklists must be included in the document control system. This is discussed in
Step 7.
VI) Consider the need to provide information about potential significant environmental
impacts associated with the transportation or delivery, use, end-of-life treatment and
final disposal of the organizations products and services.
- Some of the organization's significant environmental impacts can occur during the
transportation, deliver, use, end-of-life treatment or final disposal of its products or services.
By providing information, the organization can potentially prevent or mitigate adverse
environmental impacts during these life cycle stages.
Example: Company Y, an oil refinery, determines that the transportation and delivery of its product has
potential significant environmental impacts. Company Y determines it needs to provide information to its
transporters on the BMP to avoid potential significant impacts.
Example 2: Company Z makes electronic equipment that could contaminate groundwater if it ended up
in a landfill. Company Z determines it needs to communicate the potential hazard to the customer and
therefore displays information about the need to recycle the product on the label. It also decides that
any items replaced by the company will include a free-of-charge return shipping lable so that the
company can recycle the broken product.
In the space below, consider the potential significant environmental impacts associated
with the transportation or delivery, use, end-of-life treatment and final disposal of the
organization's products and services. What information is needed? To whom should the
organization provide that information?
Write the procedure for operational controls, see example procedure EP-08 Operational
Controls. This procedure must be maintained as documented information.
- Review emergency preparedness and response processes collected during initial environmental
review to identify any deficiencies and any situations that lack procedures.
- Update or write processes that include the proper preparatory, preventative, mitigative and
response actions to minimize adverse environmental impacts associated with emergency
situations, appropriate to the magnitude of the emergency and potential environmental impact.
- Ensure that actions are being taken to prevent and mitigate the consequences of emergency
situations.
- Set schedule to test response procedures where practicable. The testing of procedures allows
the organization and persons doing work under the control of the organization to prepare for
emergencies and evaluate the effectiveness of the procedures.
- Set schedule to periodically review and revise the processes and planned response actions, in
particular after the occurrence of emergency situations or tests. The management review (see
Step 10 for more about management review) might be a good time to conduct a review of the
process
- Ensure suppliers and contractors can access emergency contact information and procedures if
appropriate.
- Document emergency preparedness and response training requirements, completion of training,
testing and results.
Operational Controls
Significant
Operational Controls / Operational Control Operational Indicator for Affected
Aspect / Affected
Work Instructions / Document Description / Control Forms Implementation (and Contractors &
Compliance Employees
Operating Criteria Format or Records Documentation) Suppliers
Obligation
EMR REVIEW
Project is acceptable - no new environmental areas are affected, requiring no changes to the EMS.
Project is not acceptable based on the information provided (provide reasons below)
Project is acceptable - the following changes to the EMS are required
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
The results of monitoring, measurement, analysis and evaluation are used to identify both successes as
well as areas needing improvement in the EMS.
EMS Team Meeting 6 Objective: To review progress of completing work instructions and emergency
response procedures (Step 4). To establish the criteria for evaluating environmental performance and
assign responsibility for identifying the monitoring and measuring equipment, methodologies, time frame
and associated calibration requirements. To finalize environmental policy.
- Identify environmental performance criteria and appropriate indicators for each item
monitored/measured. In Step 6, the team will establish performance indicators for objectives
that will be incorporated into the monitoring and measuring system. Some of these
performance indicators for objectives may be the same as those identified in this step and some
may be new.
- Measuring equipment related to these criteria should be identified, proper operating procedures
applied and if necessary calibration requirements established. Identify and retain associated
records. Determine the frequency of monitoring and measurement and determine how often
the results will be analyzed and evaluated.
III) Identify existing and needed forms and checklists associated with monitoring and
measurement
- This may include calibration schedules and updates to training requirements.
- Forms and checklists must be included in the document control system (Step 7).
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ISO 14001:2015 Environmental Management System
Design Guidance and Timeline
Write the procedure for monitoring, measurement, analysis and evaluation, see example
procedure EP-10 Monitoring, Measurement, Analysis and Evaluation. This procedure must
be maintained as documented information.
Aspect / Method of
Compliance Monitoring,
Obligation / Criteria for Evaluating Measurement, Method of
Operational Performance / Performance Analysis and Frequency of Analysis and Frequency of Calibration
Control Being Operating Criteria / Indicators / Evaluation Monitoring and Record Retention Evaluation Analysis and Equipment
Monitored Monitoring Parameter Metrics (SOP) Measurement Type Period (SOP) Evaluation Requirements
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
EMS Team Meeting 7: Review progress of completing work instructions and emergency procedures.
Establish objectives with input from the organization’s top management. Meet in two weeks.
Create 3 Goals:
By how much? From
What do you want to achieve? By when?
what baseline?
EX. Reduce electricity usage by 5% from 2014 baseline by 12/31/2018
Write procedure to develop objectives. See example procedure EP-03. This procedure must
be maintained as documented information.
EMS Team Meeting 8: Review progress of completing work instructions and emergency procedures.
Develop programs to accomplish objectives including designating responsibility at relevant levels and
functions of the organizations and the means and timeframe to achieve them. Meet in two weeks.
Responsibility
Objective Date Due
Employee Title
Based on the Objective above, determine what performance indicators/metrics will be used to
communicate progress toward the goal.
IV) Consider how actions taken can be integrated into the organization’s business
processes.
- Consider how each goal can be integrated into all business functions from the planning stage,
through production, transportation, and waste disposal.
Example: A facility establishes an energy reduction goal. In order to assist with understanding the
energy demands and control of its production equipment, the site puts a requirement into the contracts
for all new equipment to include energy reporting devices, variable speed drives (where appropriate), and
energy star ratings (where available).
Discuss potential ways this objective can be included in business functions beyond the EHS department:
Environmental Objective
Project Plan Title: Revision Date:
Significant (S) /
Activity/ Product or Service Aspect(s) Impact(s) Compliance (C) /
Emergency (E)
Responsibility Date
Objective Date Due
Employee Title Completed
Prior to Meeting 9: The EMR may want to draft a document control process and a procedure template
with assistance from the document controller and management prior to the meeting.
Meeting 9 Objective:
To develop a document control process and apply it to existing procedures. Assign responsibility for
integrating the document control process into written procedures; allow two months to complete
integration.
- Determine the media format for each document (hard copy vs. electronic access or a
combination).
- Identify and determine how the organization will maintain control of its documented information.
Ensure all documents:
• are approved for adequacy prior to use (e.g. signature of management);
• are readily identifiable (e.g., numbering system or title);
• have an established review frequency to confirm continued adequacy;
• indicate changes and current revision status (i.e. revision number and date);
• are available at points of use;
• show linkage to relevant documentation;
• are controlled to prevent unintended use of obsolete documents;
• remain legible; and
• identify and document how to control external reference materials (e.g. environmental
permits and equipment manuals) necessary for the procedure.
- Create a template with the required information (see above) for your controlled Level 2 and 3
procedures (e.g. template header and footer). At a minimum, your document control system
must include the document title, a revision date, and reference to whom within the
organization has approval authority.
- For level 2 and 3 procedures consider incorporating additional information in your template (as
noted below) to assist in meeting ISO 14001 document control requirements. You may want
to include:
• the purpose and scope for each procedure;
• reference to associated documentation and necessary equipment;
• list of roles and responsibilities;
• benefits of following the procedure;
• environmental consequences of not following the procedure; and
• standardized format for revision language tracked over the life of document.
II) Develop a document control procedure that notes how the organization will incorporate the
information in Step I.
- Ensure the procedure assigns responsibility for document control and includes records as well as
other documents in the system.
- Consider establishing a document control form that tracks the revision history of EMS
documents, notes their location, and identifies the retention schedule for all documents (active
and obsolete). Step 7a contains an example log.
III) Format each of the organization's existing level 2 and 3 procedures using the document control
template and ensure all requirements of the document control procedure are included.
- Review the information gathered by and work products from each of the steps within this
design guidance to develop any needed procedures to formalize the organization's requirements
within the EMS.
- For Step 1 - Interested Parties (4.2), your procedure might include:
• how the organization identifies interested parties relative to its EMS;
• how the organization identifies the relevant needs and expectations of interested parties; and
• how the organization determines which of these needs and expectations become compliance
obligations.
- For Step 1 - Understanding the Organization and Context (4.1) your procedure might
include:
• process used to identify the environmental conditions affected by or capable of affecting the
organization or its EMS;
• process used to identify external issues relevant to and that can affect the EMS;
• process used to identify internal issues relevant to and that can affect the EMS;
• how the risks and opportunities associated with the above are identified; and
• how these issues are translated into environmental aspects and impacts (if applicable).
- For Step 1 - Roles, Responsibilities, Authorities and Resources (5.3 and 7.1), your
procedure might include:
• how the key environmental management roles, responsibilities and authorities are defined and
communicated to all persons working for or on behalf of the organization;
• how the EMR or assigned staff has oversight of EMS establishment, implementation and
maintenance including reporting to top management on system performance and
recommendations for improvement; and
• how resources are allocated to the EMS and authority to allocate resources.
- For Step 1 - Determining the Scope of the EMS (4.3), your procedure might include a
description of how the scope will be developed including:
• how the organization considered the issues identified by understanding its context when
developing the scope;
• how the organization considered the compliance obligations from its interested parties when
developing its scope;
• if applicable a statement of justification for excluding processes, buildings, or functions from the
EMS scope including lack of authority or ability to exercise control and influence;
• who has responsibility for maintaining and updating the scope; and
• how the scope will be provided to interested parties.
- For Step 2 - Compliance Obligations (6.1.3), your procedure might include:
• who is responsible for keeping up-to-date on compliance obligations;
• what information is needed to keep up-to-date on compliance obligations and how access it;
• the linkage between compliance obligations and an organization’s aspects (determining
which are applicable to the organization’s activities and related aspects);
• how the organization assessed any risks or opportunities associated with its compliance
obligations; and
• any reference forms used. Forms may list current legal and other requirements, reporting
dates, frequency of reporting and other information that assists in maintaining the
commitment to compliance.
- For Step 4 - Emergency Preparedness and Response (8.2) your procedure night include:
• the process for identifying potential incidents and how it will respond to those that can have
adverse impacts on the environment;
• a periodic review and testing process with subsequent revision to procedures when
necessary, particularly after a “real” emergency situation; and
• those individuals within the organization whom are responsible for ensuring these activities
take place.
- For Step 5 - Monitoring, Measurement, Analysis, and Evaluation (9.1) your procedure
might include:
• how the organization monitors key characteristics of its operations that can have a significant
impact including sources of information, frequency and measurement method;
• calibration requirements;
• how it documents monitoring of performance and progress on objectives; and
• who is responsible for ensuring these activities take place.
- For Step 6 - Environmental Objectives and Planning (6.2.1 and 6.2.2) your procedure
might include:
• how the organization establishes objectives;
• to whom and on what frequency the status of these objectives are reported;
• who is responsible for ensuring these activities take place and tracks progress;
• how often the objectives are updated;
• how the results will be evaluated and integrated into business processes; and
• references to documents listing the environmental objectives.
- For Step 8 - Competence and Awareness (7.2 and 7.3) your procedure might include:
• how training needs are identified for employees and those working on behalf
of the organization;
• who is responsible for identifying training needs;
• what process is used to determine competence for employees and those working on behalf
of the organization and who is responsible for completing it;
• how competence and training needs are identified for employees with specialized
environmental management functions (e.g. EMR, top mgt.);
• how training requirements and their completion will be tracked; and
• what forms will be used to document training completion.
- For Step 9 - Evaluation of Compliance (9.1.2) your procedure might include:
• what process is used to evaluate compliance;
• who is responsible for the evaluation;
• how often the evaluation is completed;
• determination if an independent review (corporate and third party) will be conducted;
• who will conduct the review and how often the review will occur; and
• how results from the review are communicated.
- For Step 9 - Nonconformity and Corrective Action (10.2) your procedure might include:
• a description of how nonconformances are documented and what information will be
collected;
• who is responsible for completing the various sections of the form;
• who is responsible to identifying and implementing corrective actions;
• how applicability to other areas of the facility/organization are determined and
communicated;
• how changes to written work instructions will be completed and tracked;
• how preventative actions will be documented and tracked to completion;
• how the effectiveness of the process is determined;
• who will make any necessary changes to EMS; and
• how program information will be communicated to top management.
- For Step 10 - Communication (7.4) your procedure might include:
• how environmental information will be communicated within the organization (both up and
down the management chain), how often this occurs, the method of communication, and
avenues for feedback;
• how information will be communicated to suppliers and those working on behalf of the
organization including avenues for feedback;
• how information relevant to the organization's compliance obligations will be communicated
externally and by whom;
• what process will be used to respond to communications on its EMS, how this will
documented, and who will communicate; and
• who will be responsible for internal and external communications;
- For Step 10 - Management Review (9.3) your procedure might include:
• a description of the process used, the information reviewed, responsibility for, and the
frequency of meetings;
• how the review meeting and any decisions made within it will be document; and
• how changes to the EMS and its associated processes and procedures will be assigned and
completion tracked.
- For Step 11 - Internal Audit (9.2) your procedure might include:
• the methodology for conducting audits (criteria, scope, frequency, impartiality of auditors);
• the responsibilities for the internal auditing program including planning and choice of auditors;
• how corrective and preventative actions will be handled; and
• how results from internal audits are communicated.
While this listing is intended to help identify the items to consider when developing processes and
procedures related to your environmental management system, it should not be considered all inclusive
as each system will have different documentation needs.
1.0 Purpose
The purpose of this procedure is to ensure that EMS documents are controlled – so that
changes are approved prior to use and personnel requiring access to EMS documents have the
most up-to-date document. The distribution of relevent external documents will also be
controlled.
2.0 Scope
Includes all EMS procedural documents from creation & revision to the storage & purging.
3.0 Responsibilities
The EMR is responsible for coordinating, developing, issuing and controlling EMS documents.
5.0 Procedure
5.1.1 EMS Manual - Level 1 Document. The EMS Manual describes the core elements
of the EMS and provides direction to Level 2 procedures. This document is
labeled EP-00.
5.1.2 EMS Manual - Level 2 Procedures. The EMS Level 2 Procedures describe the
methods used to accomplish the core elements presented in the EMS Manual.
These procedures are labeled EP-01 through EP-20.
Document Control
EP-07 Revision Date: March 21, 2015 Revision #4
Origination Date: August 7, 2009 Page 2 of 4
5.1.3 Work Instructions - Level 3 Documents. These are the work Instructions that
provide specific details on how to perform a given task. There are two types
of work instructions: These documents are labeled with the prefix WI.
5.1.3.1 System Level Work Instructions - are those instructions that are critical
to the effective execution of the EMS. These Work Instructions are
normally cross functional / cross departmental - in content.
The EMR will make changes to the EMS documents. Input into this step can originate
from any employee – especially the EMS Team.
All newly created procedures and forms will receive a document or form number.
The reasons for any revision to a controlled document will be recorded in the "Revision
History" section of the document.
The revision date and revision number will be updated to reflect the current informaiton
Document header) as well as on the form EF-07A (EMS Document Matrix and Revision
Log).
Document Control
EP-07 Revision Date: March 21, 2015 Revision #4
Origination Date: August 7, 2009 Page 3 of 4
5.3 Document Approval
Any documents which have been created or modified will be submitted to <SIGNATORY
AUTHORITY> who will review the requested change and will decide whether to approve
or reject the change. If the change is approved, < SIGNATORY AUTHORITY > will sign
the master hardcopy, indicating approval of the change.
If the < SIGNATORY AUTHORITY > rejects the change, the modified document will not
be signed, and notations will be made on the hardcopy as to why the approval was not
given. Copies of the rejected document will be filed with the EMR.
The EMR will coordinate the distribution of released documents and notify expected
users.
The distribution and notification of controlled external documents will also be controlled
by the EMR.
Upon receipt of the changed document, it is the responsibility of the individual being
notified to purge the obsolete documents.
If obsolete documents are retained for any reason, they should be labeled “OBSOLETE -
DO NOT USE”.
5.7 The EMR shall maintain a master set of EMS documents. The documents will be saved
electronically with hard copies of obsolete versions.
Document Control
EP-07 Revision Date: August 21, 2015 Revision #4
Origination Date: August 7, 2009 Page 4 of 4
References
6.0
ISO 14001-2015, Element 7.5
Related Procedures
7.0
EP-013 - Environmental Records
Records
8.0
ER-09A, EMS Document Matrix
EMR: Prior to Team Meeting 10, work with management to develop a procedure for evaluating
competence of those following work instructions and tracking of training. Schedule general awareness
training (policy and basic EMS overview) and targeted training related to significant aspects within the
next two months.
EMS Team Meeting 10 Objective: Continue work on and complete integration of level 2 and 3
documents and forms. Review the development of reporting and responding to corrective and preventive
actions and review plan for meeting training requirements and competence evaluation.
II) Schedule general awareness training and training for those who can have significant
impacts (7.3)
- General awareness training will include policy, significant aspects and related impacts
associated with employee’s work, contribution to the effectiveness of the EMS, and implications
of not conforming to the EMS. Consider including basic emergency response information as
well. General training is for all employees, including top management.
- Training for persons whose activities can result in actual or potential significant impacts will
require training on proper operating procedures, needs related to compliance obligations,
benefits of improved personnel performance and consequences of departure from specific
procedures.
- Document attendance at all training and make plans to provide training to absent employees or
contractors as appropriate.
- Provide information to contractors and suppliers on EMS awareness, emergency response and
work procedures as appropriate. Verify training of contractors if legal requirements apply such
as for HVAC repair, pesticide application, etc.
Use table in Step 8b to document training.
Write the procedure for competence and awareness, see example procedure EP-05
Competence and Awareness. This procedure must be maintained as documented
information.
Requirement
Competency
Awareness
ISO 14001
Additional
Department / Job Position's)
OR Employee
FREQUENCY OF TRAINING
Assessment
Related to
Competent
Instructors
Instructors
Awareness
Needed ?
Initials of
Assessor
Significant
Training
Training
Training
initials
initials
Skills, Equipment or Awareness Aspect ?
Level
Date
Date
Date
Areas (Y or N)
(1) Competency should be assessed by observation, test results, interview, or other means
NOTE : May want to set up one of these forms specific for each department or job title
EMR: The EMR may want to draft process for reporting and responding to nonconformities and
corrective actions with input from management prior to the meeting.
Team Meeting 11: Review document control process integration and make any adjustments. Develop
process for reporting and responding to corrective actions. Meet in three weeks.
Area / Department:
Corrective Action
Review Period #2:
Preventive Action
Date: Results of Actions:
Verification:
The corrective actions are _______ effective, ________not effective, ________not applicable.
The preventive actions are _______ effective, ________not effective, ________not applicable.
adequacy of resources;
relevant communications from interested parties, including complaints;
opportunities for continual improvement; and
information on the organization’s environmental performance, including trends in:
nonconformities and corrective actions;
monitoring and measurement results;
fulfilment of its compliance obligations;
audit results;
- Outputs from the review must include:
conclusions on the continuing suitability, adequacy and effectiveness of the EMS;
decisions related to continual improvement opportunities;
decisions related to any need for changes to the EMS, including allocated resources;
actions, if needed, when environmental objectives have not been achieved;
opportunities to improve integration of the EMS with other business processes,
if needed; and
any implications for the strategic direction of the organization.
- Determine how the management review shall be documented and its retention schedule.
- Step 10b contains an example management review meeting form.
V) For your EMS implementation complete a gap analysis and report to top management
on progress
- Compare existing programs and work completed against each element of the standard,
element-by-element.
- Summarize progress to date on completing and implementing EMS design requirements.
- Report to top management results of progress.
- ESI staff can perform a Gap Analysis with your assistance or can provide an Excel-based Gap
Analysis tool for your use in an internal gap analysis exercise.
Compliance Evaluations
External Communications
Environmental Performance
Objectives
Corrective Actions
Changing Circumstances
EMR: Develop a procedure for internal auditing and identify and train auditors (if necessary) and
complete readiness audit. Determine management review process.
Information collected assists in determining overall EMS continuing adequacy, effectiveness and
suitability. Each individual internal audit does not have to cover every EMS element but may instead
cover all elements in time.
Audit Checklist
Checklist for Audit Report No. Procedure No.
Section of Conforming?
Question Evidence NCR No.
Procedure Yes/No
Nonconformity Report
Area Audited: ISO 14001 Element:
Report Date: Nonconformity Number:
Reference Document(s): Category:
Major Minor
Description of Nonconformity: