ISO 14001

Gap Analysis
Digitally signed by Sherif
M. Abdou
for the
DN: CN = Sherif M. Abdou, Allegheny National Forest
C = EG, O = ICC, OU =
Industry
Date: 2007.01.27 14:17:08
+02'00'
This document provides a summary of the requirement of ISO 14001:2004, which is an
international standard describing the specification and requirements for an environmental
management system (EMS) and compares existing procedures and processes of the
Allegheny NF with the ISO 14001 standard.

EXECUTIVE SUMMARY

The ANF has many of the elements already in place that are required by an ISO 14001
EMS. The identified gaps can be characterized into the following key themes:

• There needs to be clearer and more consistent transition from step to step. For
example, planning efforts need to be better connected to operational decisions, and
monitoring processes need to more directly inform future planning.
• The directives, handbooks, project plans, and other existing documents are used to
describe how things will be done. However it is not clear that there is easy access to
these documents (especially by newer staff).
• The directives and other documents need to be reviewed to make sure they are up to
date and capture EMS requirements. As modifying these documents may be
cumbersome, especially with national and regional versions, it may be better to
develop ANF-specific procedures that supplement or complement the directives.
• There are many procedures and activities that are consistent with ISO 14001 but are
not formalized or documented. These will need to be documented and included in the
EMS documentation.
• The EMS implementation process will create procedures to conduct steps that are
needed, but may not be done currently if they are not NEPA-driven. For example,
there may be significant aspects that need to be captured in the EMS that are not
NEPA-driven.

In general, ANF appears to have approximately nearly 75% of the EMS elements in
existence. The majority of the EMS implementation effort will involve: connecting
current efforts more clearly; formalizing and documenting procedures that are already
followed “informally”; and including aspects not addressed by NEPA or other existing
requirements.

Close coordination with the NEPA process will significantly facilitate EMS development.

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 Digitally signed by Sherif M. Abdou
DN: CN = Sherif M. Abdou, C =
EG, O = ICC, OU = Industry
Date: 2007.01.27 14:21:17 +02'00'
ELEMENT-BY-ELEMENT GUIDANCE

ISO 14001 Requirement: 4.1 General requirements

An organization must establish, document, implement, and continually improve their
environmental management system and show how they meet all the requirements of this
standard. The organization defines the scope of the EMS, i.e. the boundaries of the
organization to which the EMS applies.

ISO 14001 Requirement: 4.2 Environmental Policy

The organization must have a policy, or commitment statement, developed by top
management relative to the scope of the EMS that conforms to the standard. This is
generally a short statement that drives the remainder of the EMS. There are specific
items that must be committed to in the policy, such as compliance with legal and other
requirements, prevention of pollution, and continual improvement. In addition, the
policy must be communicated to all employees, and others working on behalf of the
organization, and be available to the public. The policy provides a framework for
reviewing objectives and targets and be appropriate to the nature and scale of the entity
included in the scope. This policy must be documented, implemented, and maintained.
This means that it is kept current through the EMS review and continual improvement
process, and is implemented through the remainder of the EMS elements.

Current Facility Status

• There are USFS and USDA level environmental policies in place (may be draft at this
time).
• There is no ANF-specific policy.

Necessary Task to Conform

• Either adopt USFS and/or USDA policies as ANF EMS policy or create a new one
that conforms to ISO 14001 requirements as noted above, is consistent with USDA
and USFA policies, and reflects ANF—specific issues (if desired).
The ANF policy will need to be endorsed by ANF top management

ISO 14001 Requirement: Planning- 4.3.1 Environmental Aspects

This element requires a procedure to identify environmental aspects and related impacts
that the organization can control or have influence over, and determine those which are
significant to the organization. ISO 14001 does not prescribe what aspects should be
significant, or even how to determine significance. However, it is expected that a
consistent and verifiable process is used to determine significance.

Aspects are defined as how an organization’s activities products and/or services interact
with the environment. An impact is how an aspect changes the environment. The intent
of this element is to help the organization identify how it affects the environment,

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prioritize aspects, and use the EMS to manage, control, and improve upon the aspects.
So the organization must ensure that the significant aspects are taken into account in the
EMS.

In order to ensure that the system is continually improving and current, this information
must be kept up to date.

Current Facility Status

• Existing NEPA procedures determine how environmental aspects and impacts are
identified and prioritized.
• Plan EIS has defined the fundamental set of prioritized impacts and defined desired
conditions.
• Other, more informal processes and discussions occur to identify other environmental
issues. The robustness of these other processes varies among programs.
• Project NEPA helps manage issues that are not in the Plan EIS.
• Through NEPA, impact information is used when developing projects, activities, and
measurement.

Necessary Task to Conform

• Incorporate NEPA process by reference into EMS.
• Need to develop a supplementary procedure that provides a mechanism to identify
and prioritize aspects and impacts not covered by NEPA procedures.
• Develop a set of significance criteria against which aspects are evaluated to determine
significant aspects.
• Procedures need to ensure that aspects information inform the Program of Work.
• Program of Work (and list of proposed projects?) need to be circulated to key
program areas and departments to make sure they have input to aspects implications
of the projects. This would also help keep the aspects information up to date.
• Overall, the procedure needs to ensure that there is a clear and consistent connection
between the people and discussions that identify planning needs and those that
specifically plan out activities and projects.
• As aspects information is updated periodically, it should be informed by results of
monitoring efforts (as defined in 4.5.1).

ISO 14001 Requirement: 4.3.2 Legal and Other Requirements

This is a requirement for a procedure that explains how the organization obtains
information regarding its legal and other requirements, and makes that information
known to key functions within the organization.

The intent of this element is to identify the environmental legal and other requirements
that pertain to its operations and activities so that the organization can ensure that they
are taken into account in the EMS. In doing so, the organization must also determine
how these requirements apply to the significant aspects.

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Current Facility Status
• Programs and departments are aware of the legal and other requirements and those
are incorporated into other procedures, project plans, etc as appropriate.

Necessary Task to Conform

• Develop a procedure that clearly explains how legal and other requirements are
identified and communicated to relevant levels of ANF.
• Procedure may include a list of these requirements, which incorporates by reference
the specific information (what the requirement is, what must be done, reporting
needs, etc).
• Note that “other requirements” include Executive Orders, USDA, and USFS polices
and requirements.

ISO 14001 Requirement: 4.3.3 Objectives, Targets, and Programs

There is no requirement for a procedure in this element. However, there must be some
process that ensures that the objectives and targets are consistent with the policy, which
includes the commitments to compliance with legal and other requirements, continual
improvement, and prevention of pollution. Also, the organization must take into
consideration significant aspects, legal and other requirements, views of interested
parties, and technological, financial, and business issues when deciding what it wishes to
accomplish as an objective. The objectives and targets need to exist at whatever
functions and levels of the organization, and be measurable, where practicable.

Management programs (MPs) are the detailed plans and programs explaining how the
objectives and targets will be accomplished. These MPs usually note responsible
personnel, milestones and dates, and measurements of success. Noting monitoring and
measurement parameters directly in the MP facilitates conforming to 4.5.1 on Monitoring
and Measurement discussed below. MP’s are required for the objectives and targets in an
EMS.

Current Facility Status

• Objectives are included in the Plan, Program of Work, and specific project
information.
• Objectives are determined through group discussions among experts, in consultation
with the Plan.
• Where applicable, project NEPA helps define the details of the objectives.

Necessary Task to Conform

• Consider a procedure that describes how objectives and targets are developed (could
include the NEPA elements by reference, as appropriate).
• Procedure must verify that the “considerations” listed by ISO 14001 are addressed
when developing objectives and targets.
Digitally signed by Sherif M.
Abdou
DN: CN = Sherif M. Abdou, C =
EG, O = ICC, OU = Industry
Date: 2007.01.27 14:17:52 +02'00'
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• The procedure(s) should also explain how the programs are developed to carry out the
objectives and targets; and the programs must at a minimum include the items listed
by ISO 14001.
• The aspects procedures, legal and other requirements procedure, and this objectives
procedures should be linked to ensure a consistent connection between what is
identified as important and what is ultimately planned as action.
• The objectives procedures should be flexible enough to develop objectives and targets
for aspects not controlled by the NEPA process.

ISO 14001 Requirement: 4.4.1 Structure and Responsibility

ISO 14001 requires that the relevant management and accountability structure be defined
in this element. Top management is expected to ensure that resources are available so
that the EMS can be implemented, maintained, and improved. These resources include
human resources, organizational structure, financial and technological resources, and
others as needed.

Roles, responsibilities, and authorities must be defined, documented and communicated

as appropriate.

The organization must denote the Management Representative who is responsible to

oversee the EMS and report to management on its operation. This person(s) ensures that
the EMS is established, implemented and maintained consistent with ISO 14001, and also
reports to top management on the performance of the system including recommendations
for improvement.

Current Facility Status

• Job descriptions and organizational charts defined roles and responsibilities.

Necessary Task to Conform

• EMS-specific roles need to be included in the information (as supplements to JDs, or
as amendments).
• Consider explaining connection between Plan and Design Teams and operations
groups.
• The EMS Representative must be identified and his/her/their relationship to top
management noted.

ISO 14001 Requirement: 4.4.2 Competence, Training, and Awareness

The key point in this element is to ensure that persons performing tasks that have or can
have significant impact on the environment and/or relate to the legal and other
requirements are competent to do those tasks. Competence is ensured through
appropriate education, training, and/or experience.

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The organization needs to identify training needs as they relate to the EMS, the
significant aspects, and the legal and other requirements and make sure this training is
provided (records of such are to be maintained). A procedure is needed that makes sure
such persons are: aware of the need to conform with all EMS procedures and
requirements and what they specifically need to do to do so; the significant aspects and
the legal and other requirements associated with their respective responsibilities and why
improved performance is beneficial; and the consequences of not following these
procedures and requirements. In addition to job-specific knowledge, it expected that all
personnel within the EMS (including contractors) have general awareness on items such
as the policy and emergency response.

Current Facility Status

• Training needs are identified through IDIPs and meetings between supervisors and
staff.

Necessary Task to Conform

• Develop an EMS procedure that formalizes the link between training needs identified
for the EMS requirements and the current staff development process.
• Develop a list or matrix that illustrates what EMS-related training is needed for
respective roles and positions at ANF.
• Ensure that overall EMS awareness needs, that apply to all employees in the EMS
scope, is included in the minimum training requirements and in new employee
orientation.

ISO 14001 Requirement: 4.4.3 Communications

Procedures are required for both internal and external communications. Note that ISO
14001 only requires procedures, and allows the organization to decide for itself the
degree of openness and disclosure of information. Whatever the decision is in terms of
disclosure, the decision process must be recorded. There is a specific requirement that
the organization consider external communications about its significant environmental
aspects and record its decision.

For internal communications, the procedure needs to describe how it is done among the
levels of the organization. For external communications, it has to describe how external
communications are received, documented, and a response provided.

Current Facility Status

• Internal communications occur through meetings, memos, and emails.
• External communications are handled either through NEPA, FOIA, or ANF-specific
procedures.
• Communications of significant nature (as defined internally by ANF) go the Public
Affairs office and then on to the Forest Supervisor, as appropriate.
• Some communications handled directly by staff.
Digitally signed by Sherif M. Abdou
DN: CN = Sherif M. Abdou, C =
EG, O = ICC, OU = Industry
Date: 2007.01.27 14:18:04 +02'00'
6
Necessary Task to Conform
• Develop a procedure that captures (or incorporates by reference) the current process.
• Add to procedure a mechanism to record communications (log?, form?).
• Make a decision on external communication of significant aspects and record the
decision (whether or not it is to communicate that information externally).
• NEPA-related communications are as required by regulations and can be incorporated
by reference.

ISO 14001 Requirement: 4.4.4 EMS Documentation

This requirement ensures that the organization has documented the system in either
electronic or paper form such that it addresses the elements of the standard, describes
how the organization conforms to each element, and provides direction to related
documentation. Not all ISO 14001-required procedures need to be documented, as long
as the system requirements can be verified. However, documentation must be provided
such that enough is available to ensure the effective planning, operation, and control of
processes related to the significant aspects, and to demonstrate conformance to ISO
14001. Such documentation at a minimum includes policy, objectives and targets, a
definition of the scope of the EMS, and other main elements.

Current Facility Status

• NEPA-related documentation such as the Plan, Projects, etc currently describes the
core elements of environmental management.
• Directives, the Manuals, Handbooks, and protocols all describe procedures.

Necessary Task to Conform

• Create EMS and ISO 14001-spoecific procedures that would not now exist.
• Capture the existing documentation by reference.
• Create tables, matrices, and other directional documents that provide information
where these existing documents can be found.

ISO 14001 Requirement: 4.4.5 Control of Documents

The organization is required to control documents, such as system procedures and work
instructions, to ensure that current versions are distributed and obsolete versions are
removed from the system. There is a requirement for a document control procedure that
ensures documents are approved prior to use, are reviewed and updated as necessary,
changes to versions are identified, that the current versions are available at points of use,
that they are legible, identifiable, and that obsolete ones are so noted to avoid unintended
use. It is acceptable to use documents of internal origin in the EMS, but those must be
identified as being essential to the EMS and their distribution controlled.

Current Facility Status

• There is a Directive that describes how procedures and formal documents are to be
created, numbered, tracked, and updated.
Digitally signed by Sherif M. Abdou
DN: CN = Sherif M. Abdou, C =
EG, O = ICC, OU = Industry
7 Date: 2007.01.27 14:18:11 +02'00'
Necessary Task to Conform
Capture the existing Directive and make sure it is up to date and reflects the ISO 14001
requirements noted above

ISO 14001 Requirement: 4.4.6 Operational Control

For this element, critical functions related to the policy, significant aspects, the legal and
other requirements, and objectives and targets are identified and procedures and work
instructions are required to ensure proper execution of activities. Requirements for
communicating applicable system requirements to contractors also need to be addressed
in these procedures.

The required procedures need to provide instruction such that the organization conforms
to the policy, objectives and targets, the legal and other requirements, and addresses any
impacts from significant aspects. Which procedures are needed can be determined by
review of the significant aspects, objects and targets, the legal and other requirements,
and policy and then deciding what must be proceduralized and documented to ensure that
deviations from planned arrangements do not occur.

In regard to the contractors, the organization will need to establish procedures related to
the significant aspects the legal and other requirements, of the goods and services it uses,
and communicating the relevant elements of those procedures to the suppliers and
contractors.

Current Facility Status

• Comprehensive procedures exist (directives, BMPs, work plans, project plans, etc)
that describe how operations and activities are to be carried out, including how to
manage the environmental issues.
• Contractors and suppliers received environmentally –related instructions through
briefings and contract documents.
Digitally signed by Sherif M. Abdou
DN: CN = Sherif M. Abdou, C = EG, O = ICC, OU
Necessary Task to Conform = Industry
Date: 2007.01.27 14:18:20 +02'00'

• A clear connection between Planning elements and Operational control needs to be

made. This will show how environmental operational controls relate to significant
aspects, legal and other requirements, and objectives and targets. A table may be able
to reflect this relationship, with links to existing procedures (such as directives).
• Directives and other procedures will need to be reviewed to ensure they are up to date
and include the necessary controls as defined by the actual or potential impact of the
aspect.
• Access to these directives must b clearly understood by affected staff if they are to be
used as the operational control documentation (especially for new staff).
• The process must ensure that the planning and design input is reflected in operational
controls.

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• Operational control procedures will need to be developed for significant aspects, legal
and other requirements, and/or objectives and targets that are prompted by the EMS
and not currently addressed.

ISO 14001 Requirement: 4.4.7 Emergency Preparedness and Response

Although typically addressed through conventional emergency response plans, this
element also requires that a process exist for actually identifying the potential
emergencies, in addition to planning and mitigating them. Emergency incidents include
those that may not be regulated, but may still cause significant impact as defined by the
organization.

As part of continual improvement, it is required that the organization not only responds to
emergency situations, but also reviews the emergency procedures and make
improvements as necessary. This may involve periodic testing of emergency procedures,
if practicable.
Digitally signed by Sherif M. Abdou
Current Facility Status DN: CN = Sherif M. Abdou, C =
• Plans currently exist. EG, O = ICC, OU = Industry
Date: 2007.01.27 14:18:28 +02'00'
Necessary Task to Conform
Ensure that all potential impacts from significant aspects (as defined in 4.3.1) that can be
considered environmental emergencies are planned for in current plans. This is best done
after the aspects process is completed and potential emergency-type impacts are
identified.

ISO 14001 Requirement: 4.5.1 Monitoring and Measurement

In order to properly manage the system, measurements must be taken of its performance
to provide data for action. Procedures are required describing how the organization will
monitor and measure key parameters of operations. These parameters relate to the
operations that can have significant impacts, to monitor performance towards the
objectives and targets, and to monitor conformance to the legal and other requirements
and other EMS requirements.
Equipment related to environmental measurements, such as temperature and pH meters
and pressure gauges, must be calibrated according to procedures, and records maintained.

Current Facility Status

• Very comprehensive monitoring and measurement is done, mainly as called for by
the Plan and NEPA.
• A monitoring report is prepared as required by the Plan.

Necessary Task to Conform

• Develop an overarching procedure/matrix that relates the key parameters of
significant aspects and objectives and targets to measurement requirements.
Measurement procedures as required by this element of ISO 14001 must explain how
the measurement is to be collected and how the information recorded.

9
• Develop measurement procedures for key parameters that are identified by the EMS
but not currently addressed.
• Ensure that measurement information is forwarded to other groups as part of updating
the aspect information, checking and corrective action, and management review.
• Ensure more interdisciplinary discussions when compiling and interpreting
monitoring results.
• Procedures should ensure that monitoring information is collected and used to inform
decisions.

ISO 14001 Requirement: 4.5.2 Evaluation of Compliance

The first part of this element (4.5.2.1) requires the organization to have a procedure(s) to
periodically evaluate its compliance with applicable legal requirements as defined in
4.3.2. The organization will need to keep records of these periodic evaluations.

ISO 14001 in 4.5.2.2 also requires a similar evaluation for compliance with other
requirements. Again these are defined in 4.3.2 and the procedure can be the same as, and
even part of, 4.5.2.1.

Current Facility Status

• Compliance with legal and other requirements done, but not in a consistent manner,
and there is no formal procedure to do so.

Necessary Task to Conform

• Develop a procedure that ensures periodic evaluation of compliance with legal and
other requirements. This procedure should be connected with 4.3.2 where the legal
and other requirements were identified.

ISO 14001 Requirement: 4.5.3 Non-conformances, Corrective and Preventive

Action
This element requires procedures for acting on non-conformances identified in the
system, including corrective and preventive action. A non-conformance is a situation
where the actual condition is not in accordance with planned conditions. Someone not
following a procedure, a regulatory non-compliance, or an incident, is all examples of
possible systemic non-conformances. Non-conformances may be identified through
audits, monitoring and measurement, and communications. The intent is to correct the
system flaws by addressing root causes, rather than just fixing the immediate incident
only. The standard also requires that trends in corrective actions be evaluated to see if
deeper-rooted preventive actions can also be implemented.

The procedure needs to make sure the non-conformances are not only first addressed to
mitigate environmental impact; but that further investigation occurs to determine their
cause, and action taken to avoid it happening again. Preventive actions would then be

10
those actions resulting from an evaluation as to why nonconformities are occurring and
taking action to prevent their recurrence. The standard states that the corrective action is
appropriate to the magnitude of the problem and the impacts encountered; to avoid either
over-compensating or under-compensating for a problem.

The organization must record the results of corrective actions taken, and must also review
the effectiveness of actions taken

Current Facility Status

• Corrective action is taken as needed either as prompted by NEPA process, or by
group discussion among programs.

Necessary Task to Conform

• Develop procedures that define how EMS-related non-conformances will be
evaluated, and corrective action taken. These procedures are usually supported by a
form or database that defines who is responsible for carry out corrective action, sets
dates as deadlines, and provides for follow up to ensure the corrective action was
successful.
• The procedure should ensure that records are kept to help track corrective actions.

ISO 14001 Requirement: 4.5.4 Control of Records

Records are expected to exist to serve as verification of the system operating and the
organization’s conformance to the standard and its own EMS requirements. Procedures
in this element are required for the maintenance of records, and specifically require that
records are identifiable, retrievable, safely stored, and legible, retained as appropriate,
and traceable.

Current Facility Status

• There is a directive that describes record keeping requirements.

Necessary Task to Conform

• Supplement or modify the current directive to include EMS-related records and to
ensure it addresses the ISO 14001 requirements. Consider a table that lists EMS
element and records generated (showing how records are managed).

ISO 14001 Requirement: 4.5.5 Internal Audit

ISO 14001 requires that the system provide for internal audits. This procedure could
include methodologies, schedules, checklists and forms, and processes used to conduct
the audits. The purpose of this audit is to determine whether the system conforms to the
requirements of ISO 14001 and the organization’s own EMS detailed requirements, and
if the EMS has been properly implemented and maintained. The procedure for internal
audits has to address responsibilities and requirements for planning and executing the
audits, reporting results, and what records will be generated (and maintained in

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accordance with 4.5.4). The procedures also address determination of audit scope, how
often they will be conducted, and specifically how they will be done.

Auditors need to be selected such that it ensures objectivity and impartiality of the audit
process.

Current Facility Status

• As a formal ISO 14001 EMS does not exist at ANF, there are no EMS Audit
procedures in place.

Necessary Task to Conform

• Develop procedures to conduct an EMS audit (a generic version is attached in the
appendix). For whatever is used, ensure it captures the requirements of 4.5.4 as
defined above.

ISO 14001 Requirement: 4.6 Management Review

This element requires that periodically, top management will review the EMS to ensure it
is operating as planned, and is suitable, adequate, and effective. The organization needs
to ensure that in the review: results of internal audits (EMS and compliance); external
communications; environmental performance; status on objectives and targets; status of
corrective and preventive actions; follow up on actions from prior management reviews;
and changing conditions or situations; and recommendations for improvement are all
discussed.

Results and records of management review include: agendas, attendance records,

minutes, and documented agreed upon action items.

Current Facility Status

• Currently, formal periodic meetings are held with ANF top management to review
environmental issues.

Necessary Task to Conform

• Supplement or modify the current management meetings process to include the
requirement agenda items as defined by ISO 14001.
• Ensure records are kept of meetings, including the listing of action items.
Action items must be developed that address corrective action and future actions such
that the commitment to continual improvement is realized

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 IMPLEMENTATION PLAN AND TIME NEEDS

TASK 1 2 3 4 5 6 7 8 9 10 11 12
Identify Project Leader and Kickoff
Gap Analysis
Develop Impl. Plan
Management Overview
Develop Environmental Policy
Aspect Analysis and Sign. Det.
Develop Objectives and Targets
Develop Env. Mgmt. Plans
Review Existing Procedures
Environmental Manual
Level II System Procedures
Work Instructions
Employee Overview Training
Detail Staff Training
Align Processes and Procedures
Align Personnel and Procedures
Internal Auditor Training
Internal Audits
Corrective Action
Pre-Assessment Audit
Certification Audits

TOTALS

Notes:
• Columns are months from start.
• Internal Auditor Training includes 1.5 days each for two staff members
(Environmental Coordinator and two other employees)
• Total Days for Environmental Coordinator-

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 EXAMPLES OF TYPICAL EMS MATRICES

****************************************************************************

MONITORING AND MEASUREMENT MATRIX

Significant Aspect
and/or Objective and
Target Measurement Measurement
Parameter(s) Procedure (s)

Note: Measurement procedure may be included as part of another procedure or work

instruction. In that case, reference the host procedure.

*******************************************************************************************
CRITICAL OPERATIONS MATRIX

Significant
Aspect Critical Operation or Activity Procedure or Work
and/or Instruction
Objective
and Target

Note: Environmental procedure may be included as part of another procedure or work instruction. In that
case, reference the host procedure.

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Digitally signed by
************************************************************************************
Sherif M. Abdou
DN: CN = Sherif M.
Abdou, C = EG, O =
ICC, OU = Industry RECORDS MATRIX
Date: 2007.01.27 (For typical EMS records)
14:18:54 +02'00'
Ret.
EMS DOCUMENT RECORDS Location Time
Policy • Policy
Aspects • Aspects List
• Significant Aspects list
Legal and Other Requirements • List of Legal and other
requirements
Objectives and Targets • Minutes of meetings
where objective and
targets developed
• Past versions of
Environmental Management Programs programs
• Records of program
changes due to site
changes
Structure and Responsibility • Memos identifying
assigned responsibilities
Training Awareness and Competence • Past versions of training
needs matrices
• Training records (sign in
sheets, certificates, etc.)
Communications • Policy awareness and
distribution
• Copies of internal
communications
• Manual and related
EMS Documentation procedures
Document Control • (as per site procedures)

Operational Control • Sign-offs by suppliers

and contractors
Emergency Planning and Response • Records of drills
Monitoring and Measurement • Key characteristic
measurement records
• Records of progress

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 towards objectives and
targets
Calibration • Calibration records

Regulatory Compliance Assessment • Compliance Assessment

Reports
Corrective and Preventive Action • Completed CARs
Records Management • Properly maintained
EMS reocrds
EMS Audits • Audit reports
• Audit Schedules for
those completed
• Other audit notes as per
site procedures
Management Review • Sign in sheets
• Minutes
• Agendas
• Action Item lists

************************************************************************

LEGAL AND OTHER REQUIREMENTS

(Example)

Regulatory Specific Requirement Frequency Location of Permit, or

Requirement or Deliverable Regulatory Reference

Digitally signed by Sherif M.

Abdou
DN: CN = Sherif M. Abdou, C =
EG, O = ICC, OU = Industry
TRAINING NEEDS MATRIX Date: 2007.01.27 14:19:04
+02'00'

Position EMS Overview Policy Emer. Resp ????? ??????

Mgmt. X X

16
Maint. X X X X

Mill Mgr. X X X

17
 SAMPLE LEVEL II AUDIT PROCEDURE

Procedure:

An overall audit program will be developed. The audit program shall cover the
following points:
♦ The specific areas, functions, procedures, and activities to be audited
♦ Personnel qualified to perform the audits
♦ Audit schedule and frequency
♦ Audit processes and techniques
♦ Method of recording and reporting audit findings
♦ Development and implementation of corrective action to resolve cited audit
discrepancies

Audit Schedule and Frequency

The audit frequency shall be based on the status and importance of the EMS
elements defined in the EMS Manual, as determined by:
♦ Significant Aspects
♦ Concerns raised by interested parties
♦ Results of third party and internal audits
♦ Concerns raised by the employees
♦ Concerns raised during Management Reviews
♦ All applicable system elements shall be audited a minimum of once annually.

Audit frequency and scheduling shall include auditing all areas of the site against
all elements of ISO 14001. Audit frequency and scope for the various areas of
the site will be determined by the Audit Team Leader and communicated to the
audit team.

Audit Team Make-Up and Qualifications

System audits shall be performed by the Audit Team Leader along with a team of
trained and qualified personnel from various departments as selected by the
Audit Team Leader. To assure appropriate qualifications, the audit team may
include personnel from various departments. To assure objectivity, the audit
team should include personnel not directly responsible for the area(s) being
audited.

The audit team members will be formally trained in EMS auditing or possess
specific skills or knowledge of pertinent technical issues, environmental
regulations, management systems, and/or facility processes and products.

All personnel acting as auditors shall have received adequate training in the

18
requirements of ISO 14001 and internal auditing techniques prior to performing
an audit. Auditor orientation/training shall include as a minimum, the following
activities:
♦ A review of the relevant ISO standard 14001 and pertinent elements to
be audited.
♦ Defining of the auditor(s) role, responsibilities and auditing techniques.
♦Determining the scope of the audit and review of relevant
documents/procedures.
♦ The method of documenting the audit and non-compliance’s.

Training may be accomplished through either:

♦ The successful completion of an internal auditing course by a
recognized third party.
♦ Internal auditor training provided by personnel who have successfully
completed an internal auditor-training course.

Audit Process

For each audit, an audit team leader will be identified and shall be responsible
for:
♦ Assigning audit responsibilities to the team members
♦ Developing the audit plan
♦ Conducting audit team meetings
♦ Conducting opening and closing meetings with the auditee(s)
♦ Preparing the final audit report
♦ Communicating the findings of the audit to top management in association
with the Management Review process.

The audit plan shall consist of requirements for the following elements:
♦ Audit Team Identification
o Pre-audit Review
o Opening Meeting
o Data Collection
♦ Data Review and Analysis
♦ Closing Meeting
♦ Reporting
♦ Audit Program Evaluation

The audit team will collect data through the following means:
♦ Interviews
♦ Records review
♦ Physical inspection

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The interviews should be conducted in the work area, if possible or appropriate,
so that actual processes can be observed and any records or related data will be
available for review. Information obtained from the interview as well as the
records review and site inspection shall be documented.

A physical inspection of the facility, process, or designated areas of the facility

will be conducted and the observations and findings of the inspection
documented.

Upon completion of the audit, the audit team will meet with relevant management
and applicable department supervisors will be advised of audit results.

Audit Reporting

The EMS Internal Audit Team shall issue completed EMS Audit documents of the
audit to the Auditor Team Leader, who will prepare the audit report. The audit
report will include:

♦ Introduction – what was covered (reference Audit Plan)

♦ Description of areas reviewed and related activities
♦ Assessment date(s)
♦ Audit team and areas of responsibility
♦ Individuals interviewed and their respective areas of responsibility
♦ Audit Findings

The final audit report shall be submitted to the EMS Representative for
appropriate action.

Digitally signed by Sherif

M. Abdou
DN: CN = Sherif M.
Abdou, C = EG, O =
ICC, OU = Industry
Date: 2007.01.27
14:19:21 +02'00'

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