SAMPLE DOCUMENTATION - p2infohouse.org · Web viewISO 14001, sub clause 4.5.1 requires evaluations to be performed on a periodic basis to assess compliance with environmental regulations

APPENDIX F

Phase IV Sample Documentation

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SAMPLE DOCUMENTATION

Monitoring and Measuring

Sample Monitoring and Measuring Procedure – Charleston Public Works Commission Year End Report – Charleston Public Works

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CPW ENVIRONMENTAL MANAGEMENT SYSTEMPROCEDURE

The on-line version and secured hardcopy are the controlled documents. The secured hardcopy will be identified by an “Official Document” stamp giving date of distribution. Any and all other documents are uncontrolled. Contact EMS Program Manager for revision level status.

Effective Date: October 1, 2000 Page 1 of 2Revision: 0 Identification Number: EMS – 4.5.1 (A)Title: Monitoring and Measuring Key EMS Characteristics

Prepared By: EMS Procedures SubcommitteeReviewed By: EMS Management Steering Committee

Approved By: William E. Koopman, Jr., General ManagerJohn Cook PE, Assistant General Manager

Date Approved; August 25, 2000

ISO 14001 1996-E, Sub Clause 4.5.1 Monitoring and Measuring

1.0 Purpose

This procedure describes the process for the scheduled monitoring and measurement of key characteristics of the organization’s environmental management system activities.

2.0 Scope

This procedure addresses collection of environmental data associated with operations and activities that have the potential to have a significant environmental impact.

3.0 Responsibility and Authority

3.1 The department head is responsible for submitting a monthly operating report (MOR) which describes the key characteristics of the EMS and the status of the objectives and targets and associated improvement programs.

3.2 The department supervisor(s) are responsible for generating environmental monitoring and measurement data to be submitted in the Monthly Operating Report (MOR).

3.3 Executive management shall review the monthly operating reports to assure continuing suitability and effectiveness of the EMS.

4.0 DEFINITIONS AND ACRONYMS

EMS Environmental Management System


Effective Date: October 1, 2000 Page 2 of 2Revision: 0 Identification Number: EMS – 4.5.1 (A)Title: Monitoring and Measuring Key EMS Characteristics

Environmental Key Characteristics - an element of an operation or activity that includes a measurement or an inspection process the results of which supports evaluation of environmental performance of objectives and targets.

Monitoring - a systematic process of watching, checking, observing, inspecting, keeping track of, regulating or otherwise controlling key parameters and characteristics of a department’s management activities to determine conformance with a specific standard or other performance requirement, or to measure progress toward its environmental objectives and targets.

Measurement - a systematic method for estimating, testing, or otherwise evaluating key parameters and characteristics of a department’s management activities to determine conformance with a specific standard, other performance requirement.

5.0 Procedure

5.0.1 Monthly Operating Report (MOR)

A monthly report shall be established for department heads/supervisors to submit monitoring and measuring information to support performance of the EMS. The report is to be structured as a minimum to: Provide status of environmental management programs designed to fulfill environmental

objectives and targets, Provide status of performance indicators as related to targeted timeframes, Provide compliance status of environmental operating permits issued by environmental

regulatory agencies.

5.0.2 Performance Tracking

Environmental data collected to reflect environmental performance is to be maintained in such a manner to allow the evaluation of progress toward realizing environmental objectives and targets.

6.0 Related Documents

Environmental Aspects, Objectives, Targets, and Improvement ProgramsLegal and Other RequirementsOperating Permits

7.0 RECORDS

Monthly Operating Report

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Hanahan Water Treatment Plant

Environmental Management Systems

2000 Improvement Programs -

Year End Summary Report


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Purpose: To provide a comprehensive report on environmental improvement programs implemented by the Hanahan Water Treatment Plant Environmental Management Systems (EMS) Steering Committee to promote environmental management and continual environmental improvements.

Scope: Programs included are those conducted during the 2000 calendar year. These programs include specific significant aspects, related improvement plans and associated objectives and targets. Also included are the results and observations associated with the success of each program.

Following are the improvement plan summaries within each aspect item:

Preventive/Predictive Maintenance:

Improvement Program HM.6003-Preventive Maintenance Program:

Objective HM.6003.2: Enter all existing equipment listed in the IMT Data File Folders and the respective maintenance task instructions into CMMS database.

Target HM.6003.2: Complete entry of equipment listed in the IMT Data File Folders HI.3004.1.01 – HI.3004.1.17 and the respective maintenance tasks into the CMMS database, and post in the ISO Controlled Documents by April 30, 2000.

Target Met: April 2000

Results: As of April 28, 2000, the referenced target was met. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Effort to streamline EMS and maintenance records.


Objective HM.6003.3: Enter all revised maintenance task instructions for existing and new equipment into CMMS database.

Target HM.6003.3: Complete entry of all revised maintenance task instructions by June 30, 2000.

Target Met: May 2000

Results: As of May 2000, backlog draft task instructions (new and revised) and backlog draft datafile folders (new and revised) from 11/15/99 to 5/15/00 and match equipment to CMMS database. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Effort to strengthen CMMS task instructions with maintenance activity details provided by equipment suppliers/manufacturers. Subsequent task instruction revisions are prepared and entered into CMMS on as needed basis.



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Objective HM.6003.4: Through use of the CMMS/MP2, track preventive and corrective maintenance manhours to increase maintenance efficiency.

Target HM.6003.4: Maintain performance level of 65% PM versus 35% CM (YTD average) for 2000 calendar year.

Target Met: December 2000

Results: 64.25% PM versus 35.75% CM; margin of error 1% due to unaccounted manhours. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Maintaining an average ratio of 65%PM versus a 35% CM helps reduce overall maintenance costs and supports the company’s strategic plan. Margin of error calculated based on unaccounted for maintenance manhours.

Improvement Program HM.6004-Valve PM & Inspection Program:

Objective HM.6004.2: Increase valve lifespan and reliability.

Target HM.6004.2: Identify and exercise 60 main valves by December 31, 2000

Target Met: June 2000

Results: As of June 2000, we have identified and exercised 70 valves. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: We have exceeded the target for 2000 and continue to identify, locate, repair and exercise plant valves. CMMS task instructions have been developed for valve PM and inspection. The valve program has also identified critical main valves with special markers to allow rapid identification for emergency procedures.

Improvement Program HM.6005-Predictive Maintenance Program:

Objective HM.6005.2: Complete vibration analysis software upgrade and data translation to Odyssey. Complete chemical feed route.

Target HM.6005.2: Perform one vibration analysis on all identified equipment on chemical feed route by April 30, 2000. Enter completed information into vibration analysis database and MP2 database by June 30, 2000.


Results: Completed one (1) vibration analysis on all identified equipment on chemical feed route. Software upgraded to correct Y2K problem and to transfer data to SQL database. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: None.


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Improvement Program HM.6005-Predictive Maintenance Program:

Objective HM.6005.3: Schedule predictive maintenance using thermography technology on 25% of HWTP prime moving motors (100 HP and above).

Target HM.6005.3: Schedule thermography scanning by April 30, 2000. Generate corrective workorders from resultant report by May 15, 2000.


Results: Completed thermography scan on March 9, 2000. Generated one workorder as a result to correct identified deficiencies. No capital expenditures required. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: None.

Training:

Improvement Program HA.6006-Skills Based Training Program:

Objectives HA.6006.1: Increase basic skill level of Maintenance and I/E Associates

Target HA.6006.1: Through Technical Training Corporation (TTC) skills based training sessions and testing, increase overall skills test average score for Maintenance & I/E Associates by January 31, 2000. Compare scores to initial skills assessment.

Target Met: January 2000

Results: Table 1 identifies basic skills training topics to be covered by Technical Training Corporation for 1998 through January 2000. The date training was conducted is also included. Reported in the HWTP Monthly Report HA.7002.M.Yr.


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Table 1Basic Skill Level Training

October 1998 – January 2000Topic Date(s) Training

ConductedMechanical Training PlanShaft/Coupling Alignment 11/17/98, 11/18/98, 11/19/98, 11/25/98, 11/26/98, 11/27/98, 11/28/98,

12/01/98, 12/02/98, 12/03/98, 12/08/98, 12/09/98, 12/10/98, 12/15/98, 12/16/98, 12/17/98, 1/12/99, 1/13/99, 1/14/99, 1/19/99, 1/20/99, 1/21/99

Bearing and Seals 8/19/99, 10/14/99Lubrication /Plan Development 10/20/98, 10/21/98, 10/22/98, 11/11/99, 11/18/99Mechanical Drives 10/28/99, 11/4/99Blueprint Reading 6/17/99, 6/24/99, 7/15/99, 7/22/99, 7/29/99, 8/5/99Mechanical Principles 6/3/99, 6/10/99BenchworkTorque/Fasteners 8/12/99Pumps 9/2/99, 9/9/99, 9/23/99, 10/7/99, 10/21/99Plumbing/PipingOxe Fuel Cutting 1/26/99, 1/27/99, 1/28/99, 2/03/99, 2/04/99, 2/05/99AC Arc Welding 2/23/99, 2/24/99, 2/25/99, 3/02/99, 3/03/99, 3/04/99, 3/09/99, 3/11/99,

3/12/99, 3/16/99, 3/17/99, 3/18/99, 3/23/99, 3/24/99, 3/25/99, 3/30/99, 3/31/99, 4/01/99

Electrical Training PlanElectrical Fundamental Review 10/13/98, 10/15/98, 10/27/98, 10/29/98, 11/03/98, 11/05/98, 11/10/98,

11/12/98,11/17/98, 11/19/98

Schematic Symbols 10/20/98, 10/22/98Power Distribution 12/19/98, 12/21/98Motors and Motor Controls/Control Devices 2/09/98, 2/11/98, 2/16/99, 2/18/99, 2/23/99, 2/25/99, 3/02/99, 3/04/99, Electrical DevicesTransformers 1/26/99, 1/28/99InstrumentationPLCs 8/3/99, 8/17/99, 8/24/99, 8/31/99, 9/7/99, 9/28/99, 10/12/99, 10/26/99,

11/2/99, 11/9/99, 11/16/99, 11/23/99, 11/30/99, 12/7/99, 12/14/99,1/4/00, 1/11/00, 1/18/00, 1/27/00

National Electrical Code Requirements 6/1/99, 6/8/99, 6/15/99

Observations: The skills based training has improved the maintenance and instrumentation associates’ level of knowledge in their assigned crafts. All associates scored higher than 60 percent on their final examination for the TTC training program. This is an improvement over the original skills assessment test scores where 55 percent of the associates scored below 60 percent. The program was an overall success and has improved basic skills knowledge among the associates.


Objective HA.6006.2: Increase basic familiarity and reliability of performing CMMS task instructions.

Target HA.6006.2: Through in-house training, maintenance associates to train on 24 revised task instructions by December 31, 2000.

Target Met: Not met. Justification memo to file. New target date for completion January 31, 2001.

SAMPLE DOCUMENTATIONSAMPLE DOCUMENTATION

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Results: Completed training on 12 revised task instructions as of December 2000. Oversight on number required. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: This training program involved all maintenance associates and helped establish a better understanding of revised maintenance task instructions within the CMMS. Failure to meet prescribed target was due to oversight during training schedule preparation.


Objective HA.6006.3: Increase reliability and flexibility for taking data points on the vibration analysis routes.

Target HA.6006.3: Through hands-on training and taking one set of data collections, train two Maintenance Associates and or I&E Associates by December 31, 2000.


Results: Table 2 summarizes Hanahan WTP Maintenance Associates and I&E Associates training. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Table 2Hanahan WTP Maintenance and I&E Associates

February to December 2000Associates NameMaintenance IRD Software

TrainingH-VIB-CHM-01

H-VIB-GIB-01

H-VIB-MCCL-O1

H-VIB-PSTA-01

H-VIB-SHP-01

H-VIB-STN-01

David Kranz 2/22-24/00 4/25/00 5/23/00 5/23/00 6/01/00 4/25/00 5/02/00Lynn Shelton 2/22-24/00

3/28/00Chris Peters 2/22-24/00

3/28/004/25/00 6/01/00 4/25/00 5/02/00

I&EJack Fairbourn 2/22-24/00

3/28/004/25/00 5/23/00 5/23/00 6/01/00 4/25/00 5/02/00

Observations: None.


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Objective HA.6006.4: Increase skill level of Laboratory Chemists through training on our specific brand of Atomic Absorption Unit.

Target HA.6006.4: Through Maxwell Instruments two-day on site training program for the TJA Atomic Absorption Unit increase skill level of Chemists by September 30, 2000.


Results: The training was scheduled and performed on May 30. Three employees attended the five hour class: Lisa Myers, Chris Mantooth, and Mike Lindley. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: None.


Objective HA.6006.5: Establish a standard method of recording and documenting any training received by HWTP Associates.

Target HA.6006.5: Establish use of CPW’s Skills Based Training software. Include all current information required to complete SBT data fields for HWTP Associates and train Administration Staff by August 31, 2000.

Target Met: Not met. Objective and Target closed July 2000.

Results: Objective and Target closed. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Justification memo to file. Poor software support for ease of use and reporting. Will continue to use spreadsheets until such time as training record database can be developed using standard MS software.

Filter Media

Improvement Program HA.6001-Water Treatment Plant Pilot Study Program:

Objective HA.6001.1: Evaluate existing filter media for turbidity removal efficiency in preparation for proposed lower turbidity standard.

Target HA.6001.1: Final report to D&C Engineer to initiate project by May 31, 2000.


Results: Completed evaluation report and distributed to D&C May 2000. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Evaluation report recommended replacement of existing media in favor of new anthracite and sand design. Major capital project implemented using current funds from major capital and recurring capital.

SAMPLE DOCUMENTATIONSAMPLE DOCUMENTATION

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Chemical Systems

Improvement Program HA.6002- Net Recurring Capital Improvements Program:

Objective HA.6002.95400212: Improve chemical feed and handling systems.

Target HA.6002.95400212: Complete project by June 30, 2001.

Target Met: Incomplete. Carried over to 2001.

Results: Plans and specifications complete awaiting negotiated bid results. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Some delays because project combined with other plant improvement needs.

Monitoring & Testing:

Improvement Program HA.6002- Net Recurring Capital Improvements Program:

Objective HA.6002.00400011: Diesel fuel leak detection system.

Target HA.6002.00400011: Complete project by March 31, 2001.

Target Met: Incomplete. Carried over to 2001. Results: 99 percent of field equipment installed. Awaiting explosion proof isolators. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Project expected to be complete upon completion of new plant SCADA system. New SCADA screens complete for monitoring diesel fuel leak detectors.

Improvement Program HL.6008-Laboratory Information Management System (LIMS):

Objective HL.6008.4: Improve data handling, retrieval and report generation and tracking quality control.

Target HL.6008.4: Research options, write specifications, solicit proposals, and issue PO by December 31, 2000.

Target Met: June 2000.

Results: Our Finance Department contacted DHEC and determined that we could also qualify for state contract pricing under DHEC’s competitive bid process. We obtained a quote from Labworks and compared it to the quote obtained from DHEC and determined that the unit pricing was the same. A requisition was completed (#98002416) and entered into the CPW FMS system for approvals and issuance of a PO. Reported in the HWTP Monthly Report HA.7002.M.Yr.


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Observations: None.

Process Operations:

Improvement Program HA.6010- Partnership Program:

Objective HL.6010.1: Complete Phase III Self Assessment under requirements of the Partnership for Safe Water guidelines.

Target HL.6010.1: Submit Phase III Self Assessment Report by June 30, 2001.

Target Met: Incomplete. Carried over to 2001.

Results: No activity, awaiting appropriate staffing to complete. Reported in the HWTP Monthly Report HA.7002.M.Yr.

Observations: Delayed due to difficulty meeting staffing needs.

Conclusions:

Overall the Improvement Programs implemented to date have been successful. Each contributed significantly to environmental management, continual environmental improvement, productivity improvement, and environmental stewardship. Some of these programs have produced improvements above their original scope. An example of this is the valve identification program where main valves are marked with unique identifiers developed as a result of the program to allow quick valve identification for emergency procedures. Another example is the updated vibration analysis software and new laboratory information management software.

The improvement programs have also provided the associates an opportunity to improve their skills and job knowledge. The results are increased associate ownership in task instructions and confidence in the essential job functions for each associate involved in the program. This program has also provided a basis for cross training between crafts and will give associates the opportunity to raise their skills and knowledge of other crafts providing CPW with multi-skilled associates and work force flexibility.

The Improvement Programs provided was the opportunity for teamwork throughout the treatment plant and created a common set of goals for all departments to accomplish. Encouragement of teamwork and organization is a huge benefit derived from the improvement program which will promote an environment of continued improvement.


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Compliance Assessment

Sample Compliance Assessment Procedure – Charleston Public Works Commission

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CPW ENVIRONMENTAL MANAGEMENT SYSTEMPROCEDURE

The on-line version and secured hardcopy are the controlled documents. The secured hardcopy will be identified by an “Official Document” stamp giving date of distribution. Any and all other documents are uncontrolled. Contact the EMS Program Manager for revision level status.

Effective Date: October 1, 2000 Page 1 of 3Revision: 1 Identification Number: EMS – 4.5.1 (C)Title: Regulatory Compliance Procedure

Prepared By: EMS Procedures SubcommitteeReviewed By: EMS Management Steering Committee

Approved By: William E. Koopman Jr., General ManagerJohn Cook PE, Assistant General Manager

Date Approved: August 25, 2000

0.0 Requirement ISO 14001, Sub Clause 4.5.1 Monitoring and Measuring

1.1 Purpose

To establish and maintain a documented procedure for periodically evaluating compliance with relevant environmental legislation and regulations.

2.1 Scope

2.1 ISO 14001, sub clause 4.5.1 requires evaluations to be performed on a periodic basis to assess compliance with environmental regulations.

2.2 This procedure applies to all CPW departments.

4.0 Responsibility and Authority

3.1 It is the responsibility of the department head to ensure that self-assessments of compliance with environmental regulations and other legal environmental requirements of EMS procedure 4.3.2 are scheduled and conducted and that assessment results are documented.

3.2 It is the responsibility of CPW associates to notify their supervisor upon discovery of a regulatory non-compliance condition.


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3.3 It is the responsibility of the department head to ensure that regulatory non-compliance(s) are reported to executive management and the applicable regulatory agency as specified by the regulatory requirement.

3.4 It is the responsibility of the department head to follow-up with corrective action(s) on regulatory non-compliance(s), to return the facility to compliance as expeditiously as possible, and to document all corrective actions taken.

5.0 Procedure

4.1 SchedulingThe department head (or designee) will develop a self-assessment schedule, established on a once per quarter frequency, to assess regulatory compliance.

4.2 Site InspectionThe department head (or designee) will inspect selected site(s), observe operating conditions, interview associates on work activities and operating conditions and record observations in a factual way based upon regulatory and other legal requirements. Review of selected regulatory records, measuring and calibration records, operating criteria or standard operating instructions, shall take place before, during, and/or after the inspection.

4.3 Corrective Action PlanThe department head will promptly initiate corrective actions to resolve the regulatory non-compliance. In accordance with EPA’s 1995 Policy on Voluntary Discovery, if non-compliance cannot be corrected within a sixty (60) day period, a Corrective Action Plan will be developed. A copy will be forwarded to the section head, the EMS program manager and executive management.

4.4 Follow-upThe department head will conduct a follow-up surveillance upon completion of the corrective measures taken. If a Corrective Action Plan was developed, then a finding of closure will occur immediately upon verification of corrective action. A copy of the closure report will be submitted to the section head, EMS program manager and executive management.


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Access to these records is privileged pursuant to Code of Laws of South Carolina, Section 48-57-10 et. seq., “Environmental Audit Privilege and Voluntary Disclosure.” Distribution of the environmental self-assessment report is restricted to executive management, EMS program manager and relevant individuals within the department.

4 Related Documentation and Records

5.1 Master List of Legal Requirements5.2 Department Standard Operating Instructions and Records5.3 Self Assessment Schedules5.4 Self Assessment Reports5.5 Corrective Action Plans5.6 Follow-up/Closeout Records


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Calibration

New Hampshire Department of Transportation – Traffic Bureau

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Number: EMS-CH500-System-54-12Title: Calibration/Maintenance Management Procedure

Date of Adoption:Date of Revision:

Prepared By: EMS Program ManagerReviewed By: Implementation TeamApproved By: Lyle W. Knowlton Director of Operations

Document Control:_____ The secured hard copy signed, dated, and stamped “Official

Document” shall be the controlled document and shall be maintained by Hearings Examiner.

_____ This document and the on-line version are copies of the secured hard copy controlled document.

_____ Duplicate copies may be made and distributed, however, users must assure themselves the copied document is the current controlled copy.

_____ Earlier versions of this document are obsolete and should be removed from points of use.

D Distribution:_ _____ NHDOT intranet; bulletin boards _______________ _____ Administrators: _______________________________ _____ Supervisors: __________________________________ _____ Employees: ___________________________________ _____ Other: ________________________________________

Amendments:Summary:

1.0 Purpose………………………………………………………………… 22.0 Scope and Applicability……………………………………. 23.0 Reference……………………………………………………………… 24.0 Policy Statement…………………………………………………… 25.0Specific Responsibilities.………………………………………… 3 5.1 Bureau Administrator…………………………………………… 3 5.2 Supervisor……….………………………………………………… 3

5.3 Employee………………….…………………………………… 3 6.0 Operational Procedure….……………………………………… 3

7.0 Audit and Review………………………………………………… 4 7.1 Items Subject to Audit and Review…………………………….. 4 7.2 Record Keeping; Format; Destruction………………………… 4

7.3 Responsibility for Audit and Review………………………… 48.0 Personnel Actions…………………………………………………… 5 8.1 Discipline…………………………………………………………… 59.0 Other………………………………………………………………… 5

1.0 PurposeIn accordance with ISO 14001, § 4.4.6, the Bureau has established and adopted the following procedure.


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This procedure is to ensure the calibration/maintenance requirements of the Bureau’s operational and monitoring equipment are performed in accordance with applicable O & M manuals, standard operating instructions and/or manufacturers recommended standards., and that the operational and monitoring equipment is in compliance with the relevant environmental and regulatory requirements.

2.0 Scope and ApplicabilityThis procedure applies to the Bureau of Traffic and its statewide operations.

3.0 ReferenceEnvironmental PolicyISO 14001 § 4.4.6EMS Significant Aspects System ProcedureEMS Training, Awareness and Competence System ProcedureEMS Document Control System ProcedureEMS Objectives and Targets System ProcedureEMS Legal and Other Requirements System ProcedureRelevant standard operating procedures for equipment used at TrafficMaterial Safety Date Sheets

4.0 PolicyIt is the policy of the Bureau to assure its operational and monitoring equipment is calibrated and maintained to assure its performance in aiding the Bureau in meeting the objectives and targets of its significant aspects.

5.0 Specific Responsibilities

5.1 Bureau AdministratorThe Bureau Administrator is responsible for the calibration and maintenance program and assuring the employees have the necessary tools and training to perform the required calibration and maintenance tasks.

The Bureau Administrator is responsible for the development, revision, and issuance of appropriate calibration/maintenance standard operating instructions.

The Bureau Administrator shall ensure that the results of calibration and maintenance efforts are documented.

5.2 SupervisorSection Supervisors are responsible for assuring monitoring equipment is calibrated to appropriate specifications and operational equipment is properly maintained before its use.

Section Supervisors shall notify the Bureau Administrator of any problems with the calibration/maintenance of monitoring/operational equipment, and will set in motion a corrective action plan that will return their section’s equipment to complete compliance as soon as is practicable.

Section Supervisors are responsible for keeping maintenance records and for forwarding such reports to the Bureau Administrator for quarterly reports.

5.3 EmployeeIt is the responsibility of all employees to notify their supervisor when they discover any problems with the monitoring/operational equipment.


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6.0 Operational Procedure a. The Bureau Administrator, or his designee, shall, on a quarterly basis, document the

calibration/maintenance activities.b. The Bureau Administrator, or his designee, will direct the drafting of calibration/maintenance

standard operating instructions for its monitoring/operational equipment. These instructions will include or reference the following information where relevant.

Standard Operating Instruction TitleDocument Identification NumberRevision date and approvalDetailed maintenance criteriaSchedule and frequency of maintenance activitiesProcedural instructions on start upProcedural instructions on shut downEmergency operationInspection and test instructionsCorrective repair maintenance instructionsPreventative maintenance proceduresSafety requirementsLocation of manufacturer’s reference material

c. Following review by the Implementation Team and appropriate supervisors, the Bureau Administrator issues the approved instructions.

d. The Bureau Administrator ensures the supervisors and relevant maintenance personnel receive the appropriate training for their maintenance tasks, including training on the environmental impacts or potential consequences in deviating from the specified standard operating instructions on critical equipment and processes.

7.0 Audit and Review

7.1 Items Subject to Audit and ReviewAt least annually, the Bureau Administrator shall review this procedure to ensure the purposes for which it was created are being met in an efficient manner.

7.2 Record Keeping; Format; Destruction a. A copy of this procedure shall be maintained in the records of the Bureau of Traffic and each

relevant unit supervisor.b. This document is a controlled document. The on-line version and

secured hard copy are the controlled documents.c. The secured hard copy, stamped “Official Document” and dated,

shall be maintained by Hearings Examiner. d. Changes and updates to this procedure, and filing and destruction requirements shall be noted on all revisions to the

original copy, and all paper copies distributed to the Bureau of Traffic.

7.3 Responsibility for Audit and ReviewThe EMS Program Manager and the Bureau Administrator shall review compliance with this procedure at such intervals as they deem appropriate, but no less than annually. A written report discussing compliance with this procedure shall be provided to the Commissioners as directed, but no less often than annually.

8.0 Personnel Actions

8.1 DisciplineAs a condition of employment, all employees of the State of New Hampshire Department of Transportation are required to participate actively in Environmental Management System programs and



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follow established policies, procedures, instructions, and/or rules. Cooperation between management and employees is necessary to meet this work standard. Disciplinary action, up to and including dismissal, will be taken in cases where it is determined that disregard for environmental responsibilities has occurred. Disciplinary action will be taken in accordance with the New Hampshire Division of Personnel Administrative Rules, Chapter 1000.

9.0 OtherReserved.

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Nonconformance and

Corrective and Preventative Action

Sample nonconformance and corrective and preventative action procedure – City of Eugene, OR

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CITY OF EUGENE – WASTEWATER DIVISIONCITY OF EUGENE – WASTEWATER DIVISIONProcedureProcedure

Subject: Nonconformance and Corrective Action Document No: WW-00016R1

Prepared By:

Sharon Olson Date Prepared: 6/26/00 Revision Date: 7/31/01

Approved By: Management Team Date Approved: 8/6/01 Next Review Date: 8/1/02

Purpose

This procedure describes the process to ensure that the Division establishes, maintains and uses a system to identify nonconformances from regulations and requirements and to specify a corrective action process to identify and track areas for corrective action.

ScopeThis procedure applies to all nonconformances requiring corrective action by staff. These will typically identified by the following methods:

Internal and external audits Environmental Compliance Audits Safety Audits Inspections Incident Reports Complaints Compliance Inspections Permit Inspections

Definitions

Audit Team Corrective Action Request (CAR) Environmental Compliance Assessment EMS EMS Manager External Auditors Nonconformance

Safety RequirementsAll specific safety requirements will be included or referred to in specific work instructions.

ControlledDocument



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Procedure (Include reporting requirements and precautionary steps in this section)

Accountability: Responsibility:

Division Management Team Provide appropriate resources to ensure nonconformances are corrected.

Audit Team Conduct conformamnce audit/internal or external assessment.

Audit TeamStaff

Identify potential nonconformance and notify supervisor and Audit Team member by e-mail.

Audit Team Determine whether the potential nonconformance meets the criteria for a nonconformance and if so generate corrective action request.

Complete corrective action request form (CAR) and provide copy of form to Lead Auditor.

Lead Auditor Submit CAR information to EMS Manager, and Document Control.

EMS Manager Review corrective action request information and inform Division Management Team of any identified nonconformance that involves a potential regulatory or legal noncompliance.

Determines appropriate staff to take corrective action. Notify appropriate staff and request corrective action.

Division Staff Identify the cause of the nonconformance.

Identify appropriate corrective action. Complete Corrective Action Approval Request Form and forward electronically to EMS Manager, with copy to work section supervisor (if supervisor does not complete form).

EMS Manager Reviews Corrective Action Approval Request Form . Requests additional information if necessary. Approves recommended corrective action.

Division staffImplement the necessary corrective action.

Notify EMS Manager on completion of necessary corrective action. Include completed Corrective Action Completion Check List form.

EMS Manager Closes corrective action.

Document Control Maintain records of all non-compliance and corrective action request forms

Internal Auditors Include review of completed corrective actions in scope of audits.

References ISO 14001 Standard, 4.5.2 Non-conformance and Corrective and Preventive Action EMS Manual, Nonconformance and Corrective Action Policy Internal Audit Procedure Monitoring and Measuring Procedure Corrective Action Approval Request Form Corrective Action Completion Checklist Form Corrective Action Request (CAR) Form

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Corrective Action/Preventative Action Form

Jefferson County, AL

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This CAN is in Response to: Internal Audit: 3rd-Party Audit: Management Review: Other:

Nonconformance No.: Audit Team Leader: Audit Team Member/Requestor: Auditee Representative/Recipient:

Department: Division:

Date: Standard & Clause:

Major:

Minor: Observation: Document Reference:

Nonconformance Statement:

Root Cause:

Corrective Action Response (to be completed by Auditee):

Proposed Completion Date: Actual Completion Date: Auditee Representative:

Corrective Action Taken:

Clearance Action (to be completed by Environmental Management Representative)):

Accepted: Y N Downgraded: Y N

Follow-Up Comment:

JEFFCO

CORRECTIVE ACTION NOTICE


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This PAN is in Response to: Internal Audit: 3rd-Party Audit: Management Review: Other:

Nonconformance No.: Audit Team Leader: Audit Team Member/Requestor: Auditee Representative/Recipient:

Department: Division:

Date: Standard & Clause:

Major:

Minor: Observation: Document Reference:

Nonconformance Statement:

Preventive Action Response (to be completed by Auditee):

Proposed Completion Date: Actual Completion Date: Auditee Representative:

Preventive Action Taken:

Clearance Action (to be completed by Environmental Management Representative):

Accepted: Y N Downgraded: Y N

Follow-Up Comment:

JEFFCO

PREVENTIVE ACTION NOTICE


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Internal EMS Audit

Internal EMS Audit Procedure – City of Berkeley, CAInternal EMS Audit Report – City of Berkeley, CA

EMS Audit Checklist – Jefferson County, AL

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ISO 14001 Reference: 4.5.4 EMS Audit Created By: EMS PMLocation: Central Files EMS: System Procedures Review Schedule: BienniallyRevision: 00.03.19.02 March 19, 2002

SYSTEM PROCEDUREEMS INTERNAL AUDIT

1.0 PURPOSE

This procedure defines the process for conducting periodic audits of the Solid Waste Management Division Environmental Management System. The purpose of the audit includes but is not limited to determining continued conformance with ISO 14001 and other requirements and that the EMS is properly maintained and documented.

2.0 SCOPE

This procedure applies to the Solid Waste Management Division and its operations.

3.0 DEFINITIONS3.1 EMS Audit: a periodic process to assess the EMS against the ISO 14001 requirements and against the divisions

EMS documentation and records.3.2 Lead Auditor: an auditor who is authorized to plan, organize, and direct EMS audits in the Division. The Lead

Auditor will report findings and observations, and evaluate the adequacy of corrective and preventive action. The lead auditor should be appropriately trained for this purpose.

3.3 Audit Finding: results of the evaluation of the audit evidence compared with the ISO 14001 criteria. This could be a nonconformance or an observation.

3.4 Nonconformance: a deficiency or failure to meet the standards of ISO 14001. May be a minor missing system component, an isolated incident or any number of incidents that lead to the failure to conform completely with ISO 14001 as it relates to this facility.

3.5 Observation: a practice or the absence of a practice, while not in violation of ISO 14001, could strengthen the system or cause a system failure.

3.6 Corrective Action Request (CAR): as a result of the audit findings, CARs are assigned to all nonconformances to correct all environmental problems as they occur. This measure may also be used to correct safety and other issues on this facility.

3.7 Preventive Action Request (PAR): as a result of audit findings, PARs are assigned to any observation made that may prevent potential environmental problems before they occur.

4.0 RESPONSIBILITY

It is the responsibility of the Environmental Program Manager to routinely schedule audits and recruit or assign an internal audit team according to this procedure.

4.1 Specific Responsibilities

4.1.1 Environmental Program ManagerThe Environmental Program Manager (EPM) is responsible for developing the yearly audit schedule in June for the coming fiscal year, initiating internal audits and recruiting or assigning an audit team.

The EPM will maintain EMS audit records, including a list of auditors, audit schedules and procedures and all audit reports. The EPM will select the Lead Auditor who will be exempt from the day-to-day operations of the division during the audit cycle.

4.1.2 Lead AuditorThe Lead Auditor (LA) is responsible for notifying, organizing, planning, training and directing the Audit Team prior to and during the EMS audit.

The LA shall schedule and facilitate all Audit Team meetings, which consist of the opening, closing and any briefing meetings required.

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ISO 14001 Reference: 4.5.4 EMS Audit Created By: EMS PMLocation: Central Files EMS: System Procedures Review Schedule: BienniallyRevision: 00.03.19.02 March 19, 2002The LA initiates the corrective action or preventive action process and prepares the noticies. The LA will prepare the audit team to conduct any follow up audits needed and will prepare the final audit report, summary of findings and forward it to the EPM.

4.1.3 AuditorsAuditors are responsible for collecting, analyzing and documenting objective evidence through interviews, document examination and visual observation during the audit investigation. They shall record their observations and findings and assist the Lead Auditor in the preparation of CARs or PARs.

4.1.4 Division ManagerThe Division Manager shall provide appropriate resources to support the EMS and its audits. The Division Manager shall report progress or findings to upper management and other interested parties.

4.1.5 Senior Refuse SupervisorsThe Senior Refuse Supervisors shall provide appropriate resources to conduct the audit such as staff time, workspace and records as needed. The Senior Refuse Supervisors are responsible for ensuring the prompt and effective resolution of any corrective or preventive action audit findings and for ensuring there is no reoccurrance.

4.1.6 Refuse SupervisorsRefuse Supervisors shall facilitate the audit in any way necessary and assign an audit guide if needed. Refuse Supervisors are responsible for implementing the corrective or preventative action identified in the audit and for thoroughly training employees under their supervision.

4.1.7 EmployeesIt is the responsibility of all employees to perform their job in accordance with the appropriate operating instructions and for notifying their supervisor whenever they discover problems that may adversely affect the EMS or our legal and safety requirements.

5.0 PROCEDUREBased upon the fiscal year audit schedule, the audit process shall proceed as follows:

5.1 Audit Plan5.1.1 The Environmental Program Manager shall notify the Division Manager, the Lead Auditor and the

Audit Team of the proposed audit. The Audit Team should represent a broad section of the division activities so that individuals can be assigned to areas they do not manage or work in.

5.1.2 The Lead Auditor reviews previous audit report findings and the status of CARs or PARs prior to preparing the audit plan. Areas identified by previous audits for corrective or preventive action should be included in the scope of the audit.

5.1.3 Lead Auditor completes the audit plan. The audit plan includes the date, audit number, Scope and Objective, specify sections of ISO 14001 being audited and areas of the facility being audited, an audit schedule with auditor assignments, questionnaires and Nonconformance Report. Auditors may modify the scope and plan if necessary. These changes must be documented.

5.2 Conducting the Audit5.2.1 The Lead Auditor shall convene the opening meeting to brief the Audit Team on the general scope of

the audit, the details of the audit plan, receive input on the audit plan and schedule and discuss assignments.

5.2.2 Review key EMS documentation before touring the site and conducting interviews. Records that shall be reviewed include but are not limited to: Environmental Policy System Procedures EMPs EMS audit reports Results of Management Reviews Status of compliance with voluntary requirements

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Other relevant documents requested by Lead Auditor, Environmental Program Manager, Division Manager or other upper management.

5.2.3 Tour the site.5.2.4 Interview staff and observe activities and conditions. Responses and evidence shall be documented.5.2.5 Look for evidence to verify information from interviews through observations, records or independent

sources paying particular attention to items previously identified for corrective or preventative action or findings from other audits.

5.2.6 The Audit Team shall then meet and report on audit progress as directed by the audit plan and schedule.5.2.7 Findings and observations will be documented by the Lead Auditor; including any corrective action

taken during the audit. An internal audit report is drafted in preparation for the closing meeting.5.2.8 The Lead Auditor conducts the closing meeting to present audit findings, clarify any conflicting or

confusing information, identify positive practices, review objective evidence that supports the findings, and summarize the audit results.

5.3 Reporting Audit Results5.3.1 After the closing meeting, the Lead Auditor prepares the final audit report. The final audit report

includes a summary of the audit scope, identifies the audit team, describes the source of evidence used, summarizes the findings and results. Copies of the final report will be submitted to the Environmental Program Manager, the Division Manager and the EMS file.

5.3.2 For findings that require long-term corrective action, the Lead Auditor will prepare a CAR notice and place a copy in the EMS record system. The original will be assigned to the appropriate staff person by the Division Manager, Senior Refuse Supervisor or Refuse Supervisor as appropriate for implementation.

5.3.3 The Division Manager ensures the availability of the audit report(s) for Management Review.

5.4 Audit Followup5.4.1 The Division Manager and Senior Refuse Supervisors are responsible for any follow-up actions needed

as a result of the audit.5.4.2 The EPM is responsible for tracking the progress and effectiveness of corrective actions.

5.5 Record Keeping5.5.1 A copy of this procedure shall be maintained with the records of the division and with each relevant

staff person.5.5.2 Records shall be maintained according to the City of Berkeley Records Retention Schedule.5.5.3 The official document will have original signatures and be located in the EMS Manual in the office of

the Division Manager.5.5.4 Changes and updates to this procedure will be made in accordance with our Document Control System

Procedure and Record Management System Procedure.

6.0 AUDIT AND REVIEWThe Environmental Program Manager and the Division Manager shall review conformance with this procedure at such intervals as they deem appropriate, but no less than biennially. At least biennially the Division Manager shall review this procedure to ensure it is still relevant and meets the needs of the division.

7.0 PERSONNEL ACTIONAll employees are required to comply with all established policies and procedures of this division, the Department of Public Works, the City of Berkeley and all local, state and federal regulations pertaining to this facility. Disciplinary action will be recommended up to and including termination in accordance with established City of Berkeley procedures and SEIU Local 790, Local 535 and Local 1 labor union contracts.

8.0 REFERENCE

Public Works Environmental PolicyEMS ManualISO 14001 Documentation

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EMS Program Manager - Preparer Date

Environmental Program Manager Date

Sr. Refuse Supervisor - Reviewer Date

Sr. Refuse Supervisor - Reviewer Date

Division Manager - Approval Date

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Solid Waste Management

May 13, 2023

Internal Audit Report

STANDARD: ISO 14001

SCOPE: Assess the Environmental Management System (EMS) compliance to the ISO 14001 Standard. The audit covers EMS documentation.

Audit Team:

Team

Wanda Redic, Lead AuditorRogelio Marquina

Joe Smith

The following Internal Audit Report is an appraisal of the Environmental Management System. This audit was conducted Monday, March 18, 2002. This audit was conducted to verify conformance to the ISO 14001 standard.

In accordance with our annual audit plan the focus elements were: 4.2 [Environmental Policy], 4.4.2, [Training, Awareness and Competence], 4.4.5 [Document Control], 4.4.6 [Operational Control], & 4.5.3 [Records]. The specific areas of the Standard that were audited are detailed in the attached schedule.

SUMMARY:The audit evaluated the conformance of the EMS to the requirements of ISO 14001. There were several major findings that were documented. Observations were made and also documented.

This is the first in a continuing series of internal audits. Therefore, there were no outstanding CAR’s to be evaluated during this audit. The audit results reflect an on-going need for management to emphasize that ISO 14001 conformance requires daily adherence to all our level procedures, intensified training, management review and signatures on all documentation. ISO conformance relies on each individual employee as well as all respective levels of management in order to maintain the Environmental Management System. This emphasis should focus on ensuring all levels of the work force understand the environmental policy, have implemented the environmental system, and are working daily to maintain that environmental system.

A summary of the CAR’s is attached in Appendix A. Each CAR will soon be available on the Division directory. Each CAR will be discussed with the appropriate Supervisor regarding the nonconformance and what measures are

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needed to resolve the finding. CAR assignees will be asked to sign their CAR & agree upon a completion date. Supervisors are strongly encouraged to begin immediate corrective action. The Corrective Action Procedure is under development and will be distributed upon completion.

Appendix B contains the Agenda and Attendance List for the audit Opening and Closing Meetings. The audit schedule is presented in Appendix C.

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ISO 14001 Audit Findings (Summary)March 2002 Internal AuditMonday, March 18, 2002

Auditor ISO Clause ISO Section Findings [Corrective Action]Rogelio Marquina 4.3.1 Env. Aspects Finding: Non-conformance. Update

system procedure to include update procedure for environmental aspects.

Wanda Redic 4.3.4 EMPs Finding: Observation. Documents need review for completion and signatures.

Wanda Redic 4.4.1 Structure & Responsibility See Question 2 & 3 of Audit Protocol

Finding: Observation. Org. chart exists but is not documented in the EMS records. Include report for Gen. Section with details of staff involvement.

Wanda Redic 4.4.4 Documentation Finding: Observation. Suggestion: Add to General Requirements the ISO 14001 Standard requirements for reference. Place org charts in this section as well.

Wanda Redic 4.4.7 Emergency Preparedness

CAR: Periodic testing of emergency procedures not implemented.

Wanda Redic 4.4.7 Emergency Preparedness

CAR: Procedures do not provide means to identify potential accidents.

Wanda Redic 4.5.2 Non-Conformance & Corrective Action

CAR: No procedure on record.

Wanda Redic 4.5.3 Records Storage | Records Identified & Traceable to Activity

CAR: Records are not filed consistently. Records in multiple locations & not readily accessible. Records poorly maintained.

Wanda Redic 4.5.4 EMS Audit CAR: No procedure on record.Wanda Redic 4.6 Management

ReviewCAR: No procedure on file.

Note: This is the first EMS implemented. Management Review will be conducted when all documents conform to ISO 14001.

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Corrective Action Request’s [CAR]

0 CARS evaluated. 0 Closed, 0 Implemented, 0 progressing toward Implementation, & 0 had no change since last audit.

Status: C= Closed I= Implemented OK= Progress made NC= No Change #= # of days open

Corrective CAR’s.

Administration Responsibility Transfer Station Responsibility Collections Responsibility

CAR # Element Status CAR # Element Status CAR # Element Status

RM - 1 4.3.1

WR - 1 4.4.7

WR - 2 4.4.7 WR - 2A 4.4.7

WR - 3 4.5.2

WR - 4 4.5.3

WR - 5 4.5.4

WR - 6 4.6

* Lack of timeliness CAR.

Preventive CAR’s.

Administration Responsibility Transfer Station Responsibility Operations ResponsibilityPreventive CAR # Element Status Preventive CAR # Element Status Preventive CAR # Element Status

NOTE: The above is not a complete listing of ISO 14001 CAR’s, Only the findings of the internal desk audit are included.{database status (as of 3/18/02) shows total of 0 open CAR’s [0 corrective, 0 preventive]}.

For additional information or copies of CAR documents, please refer to the “CAR Database” in the Access 2000 database (under construction).


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Solid Waste Management

OPENING MEETINGInternal ISO 14001 Audit

March 18, 2002 11:15 a.m.

It is time for our first planned internal audit. Please sign the attendance sheet.

Scope: Assess Solid Waste Management Division environmental management system compliance to the ISO 14001 Standard. The audit will include the EMS manual and procedures and conclude with the site audit on Wednesday, March 20, 2002. Since this is our first internal audit, there are no open CAR’s to assess.

Objectives:1. The objective of the audit is to evaluate the overall organizational conformance to the ISO 14001 standard with emphasis on

elements: 4.2 [Environmental Policy], 4.4.2, [Training, Awareness and Competence], 4.4.5 [Document Control], 4.4.6 [Operational Control], & 4.5.3 [Records].

2. Evaluate and verify corrective actions from previous audits. Since this is our first internal audit, there are no corrective actions to evaluate at this time.

Copies of the ISO 14001 Checklist were provided for auditors. To verify conformance & corrective/preventive actions we will:

Review objective evidence – work instructions & environmental records.Perform Personal interviews with assignees, their employees, and responsible managementDiscrepancies will be documented on our ISO Nonconformance Report form. This process has not yet been documented.

Resources and facilities include Administration, Collections and Transfer Station Operations.

A Closing meeting will be held the week of Monday, April 1, 2002, in the SWMD Assembly Room. Brief training of EMS Audit procedures using the Environmental Policy was conducted and the desk audit began.

Desk Audit completed at 12:00 p.m. - Facility Audit scheduled for Wednesday, March 20, 2002.

Hard copies of the opening meeting attendance lists are maintained in the EMS Audit Record File.

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Closing Meeting AgendaInternal Audit March 20, 2002

1. Route and retain attendance sheet.

2. Summary of the audit activities:a. Scope and objective: The objective of the audit is to evaluate the overall organizational conformance to the

ISO 14001 standard. To assess conformance to ISO 14001 with emphasis on elements: 4.2 [Environmental Policy], 4.4.2, [Training, Awareness and Competence], 4.4.5 [Document Control], 4.4.6 [Operational Control], & 4.5.3 [Records]. Areas audited:

Clause Title Clause Title4.2 Environmental Policy 4.4.5 Document Control4.3.1 Environmental Aspects 4.4.6

Operational Control4.3.2 Legal and Other Requirements 4.4.7 Emergency Preparedness and Response4.3.3 Objectives and Targets 4.5.1 Monitoring and Measuring4.3.4 Environmental Management Programs 4.5.2 Nonconformance and Corrective and

Preventive Action4.4.1 Structure and Responsibility 4.5.3 Records4.4.2 Training, Awareness, and Competence 4.5.4 EMS Audit4.4.3 Communication4.4.4 EMS Documentation

3. Review Team's conclusion regarding the desk audit. Review corrective action and report findings.

4. Summary of Nonconformances (see attached summary).NOTE: The absence of a finding in a particular area does not mean there are none. It only indicates that this audit did not discover anything in our particular sample. The attached findings are what were discovered in the sample we took. Remember, CAR’s or Preventative CAR’s are not bad, they are opportunities for improvement.

5. Briefly explain the process for corrective action, follow-up, and closure. This process will be explained to the executive staff at their weekly meeting. 30 days to submit C&C/A, & achieve implementation. The sooner the C&C/A is approved the more of the 30 days you have for implementing. 3 steps to CAR closure: 1) Approved C&CA, 2) accomplish implementation, and 3) demonstrate effectiveness.

NOTE: C & C/A updates and re-negotiation of completion dates must be performed by the auditee [Please do this in writing, e-mail is fine].

6. Discuss submittal of internal audit report. Project Manager/Lead Auditor will submit report to EMS Champion and Environmental Program Manager no later than April 5, 2002

7. The rest of the EMS will be audited during the time period starting today and before the Registration Audit in March. The final Registration Audit is scheduled for March 26-30, 2001, and is a 3rd party audit by QSR.

8. Thank audit team for their support and close meeting.

Positive Comments

Hard copies of the closing meeting attendance lists are maintained in the EMS Audit Record File in accordance with the SSLP-1280-0016.

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SWMD Internal EMS Audit Plan - March, 2002

Audit Plan - # 03-2002

AUDIT SCOPE AND OBJECTIVE

The scope of the audit is to assess conformance to the ISO 14001 elements.

Clause Title Clause Title4.2 Environmental Policy 4.4.5 Document Control4.3.1 Environmental Aspects 4.4.6

Operational Control4.3.2 Legal and Other Requirements 4.4.7 Emergency Preparedness and

Response4.3.3 Objectives and Targets 4.5.1 Monitoring and Measuring4.3.4 Environmental Management Programs 4.5.2 Nonconformance and Corrective and

Preventive Action4.4.1 Structure and Responsibility 4.5.3 Records4.4.2 Training, Awareness, and Competence 4.5.4 EMS Audit4.4.3 Communication4.4.4 EMS Documentation

The objective of the audit is to evaluate the overall organizational conformance to the ISO 14001 standard.

TEAM MEMBERS

Lead Auditor: Wanda Redic

Team #1Wanda Redic – Lead Auditor Joe SmithRogelio Marquina

Environmental Program Manager: Becky Dowdakin

APPLICABLE DOCUMENTATION:Division EMS Manual

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AUDIT SCHEDULE

Wednesday – Opening Meeting and Desk Audit

8:30 AM - 9:00 AM Opening Meeting (Auditors)9:00 AM – 12:00 PM Facility Audit12:00 PM – 1:00 PM Lunch1:00 PM – 4:00 PM Facility Audit Conclusion

4.24.3.14.3.24.3.34.3.44.4.14.4.24.4.34.4.44.4.54.4.64.4.74.5.14.5.24.5.34.5.4

Environmental PolicyEnvironmental AspectsLegal and Other RequirementsObjectives and TargetsEnvironmental Management ProgramsStructure and ResponsibilityTraining, Awareness, and CompetenceCommunicationEMS DocumentationDocument ControlOperational ControlEmergency Preparedness and ResponseMonitoring and MeasuringNonconformance and Corrective and Preventive ActionRecordsEnvironmental Management System Audit

Functional Assessment

Wednesday March 20, 2002

Auditor ElementsAudited

Activity Building/Operation

Organization Escort Auditee

9:00 AM – 10:30AM

#1WR

4.2, 4.3.1, 4.3.4, 4.4.2, 4.4.5, 4.4.6, 4.5.3

Audit Administration Administration N/A Exec. Staff

#2 4.2, 4.3.1, 4.3.4 4.4.2, 4.4.5, 4.4.6, 4.5.3

Audit

12:00 AM – 1:00 PM

Lunch

12:45 PM – 2:45 PM

#1 4.2, 4.3.1, 4.3.4, 4.4.2, 4.4.5, 4.4.6, 4.5.3

Audit

4.2, 4.3.1, 4.3.4, 4.4.2, 4.4.5, 4.4.6, 4.5.3

Audit

3:00 PM – 4:00 PM

#1 & #2 & #3

Compile Findings, Summary & Close Out

Administration

* The functional assessment of this audit is not limited to the elements listed under "Elements Audited"

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Original signed by:

Wanda Redic, Becky Dowdakin,Lead Auditor Environmental Program Manager

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JEFFCO INTERNAL EMS CHECKIST

No. Question Y N Comments Status

Environmental Policy

This section corresponds with element 4.2 of ISO 14001 (4.1 in the ISO 14001 standard refers to the existence of an EMS)

1 Is the environmental policy defined? C2 Is the policy appropriate (sensible) to

the type, size and environmental impacts of the organization’s activities, products and services?(The policy does not have to be many pages in length to be comprehensive and yet meet the EMS requirements.)

C

3 Does the policy include a specific commitment to continual improvement?(This sub-element may have to wait for subsequent audits to verify. Continual improvement can be attributed to the improvement of the EMS system itself and not a specific performance variable.)

C

4 Does the policy include a commitment to prevent pollution?Evidence of such a commitment may be seen in the objectives and targets. This sub-element may have to wait for subsequent surveillance audits to verify.)

C

5 Does the policy include a commitment to comply with applicable legislation and regulations and other requirements that the organization subscribes to?

C

6 Does the policy include a mechanism procedures, groups/departments assigned, meetings, etc.) for setting and reviewing environmental objectives and targets

Mechanism is there through pollution prevention, continual improvement, regulatory compliance.

C

7 Is the policy documented (in a written or electronic form), implemented (all portions are being used), maintained (changed in accordance with top management decisions) and communicated evidence [sufficient sample size is to be taken] to let all employees know the contents of the policy) to all employees?

Policy was approved by the County Commission May 15, 2001 and is communicated to all fenceline employees

C

8 Is the policy available to the public?(Not necessarily distributed or sent out. Cannot be confidential or interoffice memo or letter.)

Policy is posted in public areas. Will be posted on Jeffco Website.

O

PlanningEnvironmental Aspects

This section corresponds with element 4.3.1 of ISO 14001


1 Is there a documented and maintained procedure to identify the controllable (controlled by the organization’s own actions) aspects that the organization can most likely influence? e.g.: Activity – handling of hazardous materials; Aspect – potential for accidental spillage; Product – Product “X”; Aspect – a reformulation of the product to reduce it volume; Service – vehicle maintenance; Aspect – exhaust emissions. Some organizations may identify only those aspects requiring permits. Those are not, necessarily, the only aspects at the facility. Asking questions about life cycle effects and interrelationship with the community may add other aspects.) The purpose of these procedures is to determine those aspects that have present or can have potential significant environmental impacts (e.g.: Activity [above] – Impact – contamination of soil or water; Product [above] – Impact conservation of natural resources; Services [above] – Impact reduction of air pollution.)

The aspects associated with the identified significant impacts are to be considered when setting the objectives.

(To show that the procedure is effective and implemented, the identified aspects and significant impacts are to be compared to the procedure. Review the methodology of significance and compare it with those impacts that were not chosen to be significant.)

As changes occur in operations, EMS Team will evaluate associated environmental aspects.

Add language to Section V.B. of SP-EA explaining aspects rating process.

C

C

O

2 Is there evidence of updating of the environmental aspects?(Is there a mechanism to update? This will be better audited with subsequent audits.)

On schedule but hasn’t come up yet. C

Legal & Other Requirements


1 Is there a procedure for the organization to identify and have access (access refers to availability in an understandable form to the individual who will maintain compliance) to all legal and other requirements (includes Federal, state, and local laws, permits, licenses, etc.: water, solid, air, noise, etc.) that they subscribe to that are applicable to their aspects?

(e.g. Activity [above] handling of hazardous waste regulations; Product [above] – labeling regulations; or Services [above] – automobile emission standards/requirements.)

Add summary of legal & other requirements to Sec. IV of SP-LOR. Limit scope for SP-LOR to fenceline. Define “Other Requirements” in Sec. III of SP-LOR. Add to LOR Summary a brief description of what the requirement is. Add statement to SP-LOR that we will identify legal requirements as operations change.

O

2 Is there a procedure/mechanism for the organization to secure the latest revisions of those requirements identified above?

C

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(If electronic on-line database, then latest revision probably exists, if hard copy, evidence is needed to be certain that any changes to regulations are received.)

Objectives and Targets


1 Has the organization established and maintained documented objectives (e.g. increase metal recycling) and targets (e.g. increase metal recycling by 20% by 4/02) at each relevant (a point in the organization where there is an environmental impact) function (e.g. department, building, plant, group, etc.) and level (e.g. maintenance manager and four floor personnel) within the organization? (Objectives and targets should be set for all significant environmental aspects.)

(Objectives and targets may be in different documents. The overall numbers may be in identified permits or policies or plans but there needs to be objectives and targets set for relevant functions and levels of the organization. This may also be in job descriptions, goals of the departments, etc.)

When establishing objectives, the organization shall take into consideration legal and other outside requirements, technologies and financial options, business and operational considerations as well as views of interested parties.(Look for evidence of a methodology or some analysis and be sure the chosen objectives are consistent with the methodology.)

As baseline data becomes available, quantify targets in percent or dollars if possible.

Objectives & target data not properly recorded for four facilities.Data was available, but not in proper format.

Minor N

C

2 Are the objectives and targets consistent with the environmental policy?

(Is there consistency between the objectives/targets and the environmental policy? Consistency does not mean that we need to have objectives and targets for commitments in the policy.)

C


Environmental Management Programs


1 Does the program include the designation of responsibilities at each relevant function and level?

C

2 Does the program include a schedule and the resources necessary to achieve the objectives and targets? (The plan may be a developing plan with changes and amendments as requires.)

Specify source of resources and specify end dates where possible.

O

Implementation and OperationStructure and Responsibility

This section corresponds with element 4.4.1 or ISO 14001

1 Are roles, responsibility and authorities defined, documented, and communicated?

(Can be in the form of an organization chart, but does not have to be.)

NOTE: Be sure of sufficient sample size of the evidence.

C

2 Has management provided the necessary resources for this EMS?

(Resources include people, technology, money, etc. The organization decides what and how much of the resources are required. Evidence of this may be in the environmental program – 4.3.4 of the standard.)

C

3 Has top management appointed an environmental management representative?

(A team is acceptable.)

C

4 Are the roles of management representative documented to include:

a. ensuring that the EMS requirements established, implemented and maintained in accordance with ISO 14001;

b. reporting on the performance of the EMS to top management for review management review – 4.6) and as a basis for improvement of the EMS?

Management Review scheduled for early February

C

C

Training, Awareness, & Competency

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1 Have training needs been identified for those whose work has or can have a significant environmental impact?

(These are individuals associated with significant aspects.)

C

2. Has the appropriate training been performed?

(evidence of training.)

Not complete at one facility. Training has been scheduled for late January and early February 2002.

MinorN

3. Are there procedures that are documented and maintained to give employees at the relevant functions and level an awareness of the following:

(The employees to be considered here are to be the same as those identified to be trained in 4.4.2 first paragraph. Being made aware the consequences of a task is different than being trained to perform the task.)

a. the importance of conformance with the environmental policy and procedures and with the requirements of the EMS;

b. the significant environmental impacts (actual or potential) of their work and the environmental benefits of improved personal performance;

c. their roles and responsibilities in conformance with the environmental policy and procedures and with the requirements of the EMS; and, (Including the emergency preparedness and response requirements as stated in 4.4.7 of the standard.)

d. the potential consequences of not following the specified operating procedures and responsibilities assigned to them?

(Evidence of the above being communicated to the proper employees may be in the form of training records or work instructions or some other document. The evidence needs to show that the employee was made aware of and understood the above information. On the job training may be accepted but evidence is still required that the above was conveyed to the specific employee. Asking random employees

All employees surveyed know the importance of conformance with the Environmental Policy and requirements of the EMS. All also knew significant environmental impacts of their work. A few (3) had to be prompted.

C

C

C

C

C

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to verify their knowledge and awareness of the above points will also verify the effectiveness of this element.)

4. Has a determination of competency based on education, training, or experience been made for personnel performing tasks which can cause significant environmental impacts?

C

5. Are all workers provided with awareness training (including those not associated with significant environmental impacts) on the following:

a. the importance of conformance with the environmental policy and procedures and with the requirements of the EMS;

b. the environmental benefits of improved personal performance;

c. emergency preparedness and response; and,

d. encouragement to look at their own task (job) for opportunities and things to watch out for?

NOTE: For all of the above, be sure of a large enough sample size of evidence.

Emergency preparedness and response training will be added to New Employee Orientation.

C

C

Minor N

C

Communication


1. Are there procedures and records that are maintained for the following types of communications and activities regarding the organization’s environmental aspects and its overall EMS: (both aspects and EMS)

a. internal communications between different levels (e.g. managers to supervisors, supervisors to line workers, etc.) and different functions; and,

b. the receiving (processing) documenting (logging) and responding (sending out answers) to relevant (the organization defines “relevant communication”) communications from external interested parties? (Interested parties, such as, community groups, government agencies, individuals, etc.)

C

C

C

Environmental Management

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System Documentation


1 Is the EMS documented?

(Document is to provide a general description. The EMS Manual, if it exists, can satisfy this.)

Manual is in place C

2 Does the documentation include the core elements of this standard?

Specified in System Procedures C

3 Does the documentation address the interaction (organizationally and in the flow of information) of the different parts of the system?

(e.g., How is information on new regulatory requirements or changes to operational procedures transmitted to individuals that need to know?)

Through references to related documents.

C

4. Does the documentation point to supporting systems?

(Does the system document how the related information [regulations, permits, forms, etc.] is to be used?)

Through System Procedure and Operating Procedure elements

C

Document Control


(There may be different methods and different people for different types of documents but the constraints must be specified.)

1 Are there procedures for controlling all documents required by this standard?

(Include all documents that are referred to in this standard such as policy and procedures and documentation.)

C

2 Are the documents accessible?

(This may include accessibility on a network or similar database.)

In paper form and electronic C

3. Are the documents periodically (the organization must state the period but the words “as needed” are not acceptable) reviewed (evidence of review is required), revised (in a controlled manner), and approved (evidence required) for adequacy by authorized personnel? (“Authorized” must be clear in a documented format or obvious from organization structure of some other means.)

C

4 Are the latest versions of the appropriate documents available (can be from an electronic database) in areas

C

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where personnel perform tasks essential to the effective functioning of the EMS?

(e.g., The one who monitors an effluent stream needs the procedure and form for taking the sample and recording the results and the administrator of the program needs to have regulatory requirements available, although it may be on an electronic database.)

5 Are obsolete documents removed from use of otherwise protected against unintended use?

C

6 Are those obsolete documents that are retained for legal or knowledge reasons clearly identified?

Stamped “Obsolete” C

7 Are documents dated (the standard actually requires dating) with the latest revision, kept orderly, legible and retained, is necessary, for a specified period?

(Organization must state the retention period.)

C

8 Are there procedures that define the “who and how” of creating or modifying documents?

C

Operational Control


1 Have operational controls been developed for operations and activities associated with significant environmental aspects?

(The significant aspects were derived from an analysis of operations and activities.)

Operating Procedure for ink use not in place, all others are in place.

No PPE on hand at one facility (on order), all others are in place.

MinorN

MinorN

2 Does the maintenance plan (if one exists) ensure that operational controls remain in operation?

Computerized maintenance programs are used except at 2121 Bldg.

C

3 Have procedures been established and been maintained to cover situations when operational controls fail?

C

4 Are operating criteria (e.g. temperature, pressure, flow) clearly established and documented for operations controls?

C

5 Have procedures and requirements related to significant aspects of goods and services been developed and communication to suppliers and contractors?

On PACA website. C

Emergency Preparedness and Response

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1 Are there maintained procedures to identify potential for accidents and emergency situations?

(Emergency situations may be obvious or may not be in certain facilities. Emergencies may not exist in all situations but accidents can always happen. “Potential” can be ascertained by an analytical evaluation or a subjective one, but some evidence of evaluation is required.)

C

2 Are there maintained procedures to respond to accidents and emergency situations and to prevent and minimize the environmental impacts that may be associated with them?

Emergency phone numbers not posted in Greenhouse.

CO

3 Are there reviews and revisions (specifying frequently is not required) of the emergency preparedness and response procedures, particularly after an incident?

(After an incident, there will be evidence of a review of the procedures.)

C

4 Are there periodic tests of the above procedures?

(Tests may not be practical in all types of emergencies. Some tests may be simulations.)

Some have been tested, others are scheduled.

O

Checking and Corrective ActionMonitoring and Measurement


1 Are there documented and maintained procedures to monitor and measure, on a regular (specified by the organization) basis, the key (to be determined by the organization but to be logically based) characteristics (variables such as temperature, pH, flow, % of contaminant, etc.) of its operations (e.g. process type tasks) and activities (e.g. testing and inspecting type tasks) that can have a significant impact on the environment?

C

2 Is there a calibration system for monitoring equipment?

Storage tanks, Freon Leak Detectors C

3 Does the organization maintain a documented procedure for periodically (the organization decides on the

Quarterly C

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frequency) evaluating compliance with relevant environmental legislation and regulations?Non-Conformance and Corrective and Preventative Action


1 Are there maintainable procedures for defining responsibility and authority for handling, investigating and taking action to minimize impacts of nonconformances?

(Nonconformances are findings that are contrary to this standard or contrary to the organization’s own procedures. It is possible that a noncompliance to regulatory requirements may also indicate nonconformity to ISO 14001 or to the organization’s procedures.)

C

2 Are there maintainable procedures for initiating and completing corrective and preventive action?

C

3 Are the corrective and preventive actions taken appropriate to the magnitude of the problems and commensurate with the environmental impact found? (This is a judgment call.)

C

4 Are the results of the corrective and preventive actions implemented and recorded?

Will be recorded when implemented.

C

Records


1 Are there maintainable procedures for the identification, maintenance, and disposition of environmental records? These records shall include (the standard does not exclude other records to be identified as “Environmental Records”) training (4.4.2), records and the results of audits (4.5.4) and reviews (4.6).

(Records that are not specifically identified as “Environmental Records” but are part of the EMS still must follow the guidelines of 4.4.4 and 4.4.5 of the standard.)

C

2 Are the records legible, identifiable and traceable to the activity, product or service involved?

C

3 Are the records stored and maintained such that they are readily retrievable and protected against damage, deterioration or loss?

Paper and electronic copies. C

4 Are there documented specified C

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retention times for all of the records identified?

5 Are the records maintained in a manner to demonstrate accordance with the standard and appropriate to the system and the organization?

(e.g., Are the records consistent with the intent and content of this standard and yet appropriate for the size and type of organization?)

C

Environmental Management System Audit


(The standard does not refer to this sub-element as “an internal audit”. Therefore, it does not have to be performed by employees of the organization.)

1 Is there a maintainable procedure or procedures for periodic (organization decides frequency) EMS audits?

(The audits must be EMS audits, not compliance type audits. It is possible and acceptable to have compliance audits as part of the EMS audits.)

C

2 Does the procedure for EMS audits include:

a. the scope of the audit (the standard states that the plan and schedule shall be based upon environmental importance of a particular activity and the results of the previous audits);

b. frequency;c. methodologies used (check

lists, etc.);d. responsibilities (Auditors must

be properly qualified per 4.4.2 to perform EMS audits.);

e. requirements; and,f. reporting results? (To whom,

in what form, timeliness.)

(The standard does not address independence of the auditor of the area audited. The registrar will expect independence enough to assure credibility by the auditor. This is a judgment call by the registrar’s auditor.)

C

CC

C

CC

3 Does the EMS audit determine whether the EMS has been implemented and maintained and conforms to this standard?

(Is there an overall assessment of the organization’s EMS?)

C

4 Does the EMS audit provide results of C

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the audits to management? (for 4.6)Management Review

This section corresponds with element 4.6 of ISO 14001

1 Has the top management performed a documented review of the EMS on a periodic (frequency is chosen by the organization) basis?

First Management Review is scheduled for early February 2002

O

2 Does the review address:a. the system’s continued

suitability;b. the system’s adequacyc. the system’s effectivenessd. the system’s possible need to

change its policy;e. the system’s possible need to

change its objectives and other elements of the EMS in light of the audit results, continual improvement, etc.; and,

f. the system audit as required in 4.5.4?

Review not yet conducted. O

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Management Review

Sample Management Review Procedure – Port of Houston Authority, Houston, TXSample Management Review Quarterly Report – Jefferson County, AL

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Procedure No 4.5.15 Prepared by: EADEffective Date: 1/23/02 Reviewed By: EMS Core TeamRevision No. : 0 Approved By: Wade Battles

Signature & Date:

1.0 Policy Reference:

Provide and promote proactive environmental leadership and compliance in all business decisions, pollution prevention, best management practices and policy programs, while attaining the widest range of beneficial uses for the environment.

Continually evaluate and improve activities and practices to achieve our established goals of meeting and/or exceeding all current Federal and State standards and regulations.

2.0 Purpose

The purpose of this procedure is to document and develop a primary agenda of issues to be included in the Senior Management Review meeting for evaluating the status of the PHA’s EMS.

3.0 Scope

This procedure applies to all Management Review meetings conducted at the PHA.

4.0 Responsibility & Authority

4.1 Senior Management

Attend Senior Management Review meetings and provide feedback to the Environmental Affairs Manager and the EMS Core Team.

4.2 Director of Protection Services, Facilities, and Operations, and the Container Terminals Manager

Attend Senior Management Review meetings, and provide feedback to the Environmental Affairs Manager and the EMS Core Team.

4.3 EMS Champions

Attend Senior Management Review meetings and assist the Environmental Affairs Manager with discussion.

4.4 EMS Core Team

Develop Agenda for the Senior Management Review meeting

4.5 Environmental Affairs Manager

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Scheduling and conducting semi-annual management review meetings during each 12-month period.

Ensuring all necessary data and other information are collected prior to the meeting.

5.0 Procedure

The Senior Management Review process is intended to provide a forum for reviewing and/or improving the PHA’s EMS on a semi-annual basis, and to provide management with a vehicle for making any changes to the EMS necessary to achieve its goals.

5.1 At a minimum, each Senior Management Review meeting will consider the following:

Suitability, adequacy, and effectiveness, of the environmental policy

Suitability, adequacy, and effectiveness of the PHA’s Objectives and Targets and the status thereof;

Suitability, adequacy, and effectiveness of the PHA Environmental Management Plan and Performance Indicators

Suitability, adequacy, and effectiveness of corrective and preventative action plans;

Suitability, adequacy, and effectiveness of any EMS audits conducted since the last Senior Management Review meeting

Suitability, adequacy and effectiveness of training efforts; and,

Results of any action items from the previous Senior Management Review meeting.

Providing direction for changes needed to the EMS.

5.1 Meeting minutes will be generated by the Environmental Affairs Department and will include, at a minimum the list of attendees, a summary of key issues discussed and any actions items arising from the meeting.

5.2 A copy of the meeting minutes will be distributed to attendees and any individuals assigned action item. A copy of the meeting minutes will be retained on file in the Environmental Affairs Department.

6.0 Related Documents

4.2.1 Environmental Policy4.3.13-14 Objectives and TargetsEnvironmental Management Plan4.4.11 Training, Competency and Awareness4.5.11 Corrective Action Procedure

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EMS - Management ReviewIncluding Quarterly Report to Management

Presented by: Bill Peters, EMR

02/13/20027:30 AM General ServicesConference RoomBirmingham, AL 35203

Reference:

ISO 14001, Section 4.6 requires the following:

The organization’s top management shall, at intervals that it determines, review the Environmental Management System (EMS), to ensure its continuing suitability, adequacy and effectiveness. The management review process shall ensure that the necessary information is collected to allow management to carry out this evaluation. This review shall be documented.

The Management Review shall address the possible need for changes to policy, objectives, and other elements of the Environmental Management System, in the light of Environmental Management System audit results, changing circumstances, and the commitment to continual improvement.

I. INTRODUCTION

The semi-annual review of our EMS by top management is an important component for ensuring that we keep our commitment to continual improvement and for ensuring that the EMS is effective in meeting our needs over time.

II. SCOPE

The management review process is intended to provide a forum for discussion and improvement of the EMS and to provide top management with a vehicle for making any changes needed to the EMS.

III REVIEW OF INTERNAL AUDIT RESULTS (Attached)

The Internal Audit conducted January 21-23 evaluated the conformance of the Jeffco EMS to the requirements of ISO 14001. There were no major findings. However, five minor findings and five observations, or suggestions for improvement, were documented.

This is the first in a continuing series of internal audits. Therefore, there were no outstanding Preventive or Corrective Action Notices (PAN/CAN) to be evaluated during this audit.

The audit results reflect an ongoing need for management to emphasize that ISO 14001 conformance requires daily adherence to all our EMS procedures. ISO conformance depends on


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each individual employee and all levels of management understanding their roles and responsibilities and working to implement and maintain the environmental management system.

All areas audited displayed competency and professionalism.

IV REGULATORY ASSESSMENT REPORTS (Attached)

There are no known noncompliance issues related to the EMS at this time.

V REVIEW OF OBJECTIVES AND TARGETS AND RELATED SIGNIFICANT ASPECTS (Attached)

VI INTERESTED PARTY ISSUES

The Environmental Protection Agency (EPA) has announced its intention to select and provide technical assistance for up to five existing not-for-profit organizations in order to increase their capacity to assist public entities wishing to adopt environmental management systems (EMS). The assistance provided to these organizations will include help with developing business plans, providing EMS education materials, train-the-trainer work sessions on ways to address the needs of public agencies, and other marketing services. These five Local Resource Centers will be tied to the National Public Entity Environmental Resource (PEER) Center.

Jefferson County has applied to be designated as one of the Local Resource Centers. If selected, we will partner with the Environmental Management Department at Samford University and with the Birmingham Chamber of Commerce.

VII REVIEW OF THE ENVIRONMENTAL POLICY

The Jefferson County General Services and Fleet Management Departments are dedicated to best management practices in the allocation of public resources for the benefit of its citizens with an ongoing commitment to continual environmental improvement through employee training, prevention of pollution, and full compliance with all appropriate legal and other requirements.

VIII ENVIRONMENTAL MONITORING AND MEASUREMENT DATA

Monitoring and measurement data are maintained for the following:

Fuel Tanks – No reported monitoring or measurement errors Freon Leak Detectors – No reported monitoring or measurement errors

IX CONTINUING SUITABILITY OF THE EMS IN RELATION TO CHANGING CONDITIONS AND INFORMATION

New or Modified Laws and Regulations Training Needs and Status of Training Requirements

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Technology Improvements Changes in Key Suppliers

Attachments: Nonconformance & Observation Report Regulatory Assessment Reports Progress Report of Objectives and Targets Positive Comments


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