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EMS 1006.7210.13GAugust 11, 2014Page 1 of 14ENVIRONMENTAL MANAGEMENT SYSTEMOPERATING PROCEDUREInternal EMS Conformance AuditsEffective Date: August 11, 2014Christopher TaylorPLMG/SIIM(ISSS)APPROVED://SIGNED//Peer Reviewer8/18/2014Date//SIGNED//Independent QA Reviewer8/20/2014Date//SIGNED//Designated Safety, Health and EnvironmentalManagement LED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 2 of 14TABLE OF CONTENTSA. PURPOSE AND APPLICABILITY . Page 3 of 15B. DEFINITIONS . Page 3 of 15C. PROCEDURAL STEPS . Page 3 of 15D. RECORDS MANAGEMENT. Page 5 of 15E. QUALITY ASSURANCE AND QUALITY CONTROL. Page 5 of 15F. REFERENCES. Page 6 of 15ATTACHMENTS:Attachment 1. Region 7 Audit CriteriaUNCONTROLLED WHEN PRINTEDTotal Pages: 10
EMS 1006.7210.13GAugust 11, 2014Page 3 of 14A. PURPOSE AND APPLICABILITYThe purpose of this Operating Procedure (OP) is to establish a uniform process for assessing the state ofconformance of the Region 7 Environmental Management System (EMS), under the Region’s AuditProgram (EMS 1006.5100.01), to the ISO 14001 international standard. This OP applies to all facets ofthe Region’s EMS scope.In accordance with the Region’s EMS Audit Program, internal audits of the system must be conductedonce per EMS cycle unless the EMS Coordinator, with agreement from the Region’s SeniorManagement, determines that an external audit substantially meets the requirements of the AuditProgram.B. DEFINITIONSAll definitions may be found in the document titled US Environmental Protection Agency Region 7Safety, Health, and Environmental Management System Terms and Definitions (SHEMS 1006.9000.02)contained in the EMS Manual. For the purposes of this OP, the following terms apply: AuditorCorrective ActionEMS DocumentEMS RecordInternal AuditNonconformanceSenior ManagementC. PROCEDURAL STEPS1. The EMS Coordinator will identify the Lead Auditor based on the following criteria:a. If the Lead Auditor is selected from within Region 7, they must have successfully completedan EMS auditing course, the Region’s EMS Awareness Training Course, and the currentversion of the Region’s EMS Refresher Training Course. They must also have experiencewith conducting EMS audits; additional experience as a compliance inspector or conductingquality audits, along with report writing, is desirable. The EMS Coordinator will securepermission from the Lead Auditor’s supervisor to participate in the audit and lead the AuditTeam.b. If the Lead Auditor is selected from outside Region 7, they must have successfully completedan EMS auditing course or served in the position of EMS Coordinator within theirorganization for a minimum of 2 years. In addition, they must also have experience withconducting EMS audits; additional experience as a compliance inspector or conductingquality audits, along with report writing, is desirable.2. The Lead Auditor and the EMS Coordinator will create the Audit Plan (an EMS Document) forthe audit in accordance with the Region’s Audit Program.a. The Audit Scope will be determined by the EMS Coordinator as defined in the most currentversion of EMS 1006.5100.01.b. The Audit Schedule may be established by the EMS Coordinator, jointly by the Lead Auditorand the EMS Coordinator, or by the Audit Team at the discretion of the EMS Coordinator.c. The Audit Criteria, derived from ISO 14001:2004(E), are specified in Attachment 1.UNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 4 of 143. The Lead Auditor and the EMS Coordinator may identify additional members of the Audit Teambased on the scope and complexity of the audit. If additional team members are needed, they willbe selected based on the following criteria:a. If the members of the EMS Audit Team are selected from within Region 7, they must haveattended the Region’s EMS Awareness Training Course and the current version of theRegion’s EMS Refresher Training course. Completion of an EMS auditing course is highlydesirable, as is experience conducting EMS audits, quality audits, and/or complianceinspections. The EMS Coordinator will secure permission for the EMS Audit Team membersto participate on the team.b. If members of the EMS Audit Team are selected from outside Region 7, they mustdemonstrate completion of EMS training comparable to the Region’s EMS AwarenessTraining Course. Experience conducting EMS and/or quality audits or as a complianceinspector is desirable.4. The Lead Auditor will assemble the Audit Team prior to the scheduled date of the audit toreview the Audit Plan and assign roles and responsibilities for the conduct of the audit. Trainingwill be provided to the Audit Team members on auditing techniques and the procedures includedin this OP using a competency training program developed by the EMS Coordinator (an EMSdocument) and provided to the Lead Auditor. These duties may be performed by the EMSCoordinator with concurrence of the Lead Auditor. NOTE: The EMS Coordinator will not allowthe audit to begin until proof of training has been received.5. The Lead Auditor will schedule interviews with senior managers, mid-level managers, and otherstaff, in accordance with the Audit Plan, prior to the audit start date. The Lead Auditor will alsocomplete any logistical arrangements needed to conduct the audit such as securing rooms for theopening and closing conferences, workspace for the audit team, and audiovisual equipment (i.e.,digital cameras and projectors). These duties may be performed by the EMS Coordinator withconcurrence of the Lead Auditor.6. The Audit Team will conduct the audit in a fair and impartial manner using document reviews,interviews with specific personnel who have EMS roles and responsibilities (e.g., seniormanagers and program managers), interviews with the Region’s employees and contractors, andvisual observation to assess the level of conformance of the EMS. A suggested plan for obtainingobjective evidence is included with the audit criteria found at Attachment 1.7. The Audit Team will meet with the EMS Coordinator (and others at the discretion of theCoordinator) to discuss potential discrepancies noted during the audit. The purpose of thismeeting, which can occur one or more times during the audit, is to obtaininformation/clarifications on the circumstances surrounding the finding that could aid the AuditTeam in determining the classification of the finding (a major non-conformance, a minornon-conformance, or an opportunity for improvement). Positive observations and bestmanagement practices (BMPs) may also be noted. While the EMS Coordinator may provideinput, decision authority as to the classification of a finding rests solely with the Audit Team.8. A closing meeting will be held in accordance with the Audit Plan to debrief the results of theaudit. The EMS Coordinator will be present at the closing meeting; one or more members ofSenior Management and one or more members of the various EMS teams may also attend if theyso desire.9. The results of the audit will be documented in an audit report (an EMS document), prepared bythe team in accordance with the Audit Plan, using the Audit Report Template (EMSUNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 5 of 141006.5200.00). Delivery of the report constitutes the completion of the internal audit process. Allnotes generated by the Audit Team during the audit will be submitted with the audit report.10. The EMS Coordinator will review the audit report and develop a disposition memorandum thatprovides background information on the findings and observations. The memorandum will alsoidentify whether or not they will be followed-up on and, if so, if they will be managed using theRegion’s Corrective and Preventative Action Process, as defined in the current version ofSHEMS 1006.7210.12, or some other mechanism.D. RECORDS MANAGEMENTThis OP requires the generation of the following records:RecordResponsible PersonRecord LocationAudit Team TrainingEMS CoordinatorEMS Working FilesAudit Team CompositionEMS CoordinatorEMS Working FilesThis OP may also result in the generation of additional EMS records. Any records created will bemanaged in accordance with the most current versions of SHEMS 1006.7210.02, Document Control,and SHEMS 1006.7210.17, Records Management.E. QUALITY ASSURANCE AND QUALITY CONTROLThe quality assurance and quality control (QA/QC) success of the procedure for assessingenvironmental compliance, as detailed in this OP, will be determined through the internal and externalEMS conformance audit processes. Deficiencies noted during these audits will be managed through theRegion’s Corrective/Preventive Action Process as defined in the current version of SHEMS1006.7210.12.F. REFERENCESCurrent versions of the following references are assumed if no date is provided.1. ISO 14004:2004(E); Environmental Management Systems – General Guidelines on Principles,Systems, and Support Techniques; November 15, 20042. US EPA R7, US Environmental Protection Agency Region 7 Safety, Health, and EnvironmentalManagement System Terms and Definitions (SHEMS 1006.9000.02)3. US EPA R7, Document Control, SHEMS 006.7210.024. US EPA R7, Corrective/Preventive Action Process, SHEMS 1006.7210.125. US EPA R7, Records Management, SHEMS 1006.7210.176. US EPA R7, EPA Region 7 Environmental Management System Audit Program, EMS1006.5100.017. US EPA R7, EMS Audit Report Template, EMS 1006.5200.00UNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 6 of 14ATTACHMENT 1Region 7 Audit CriteriaAudit CriteriaSuggested Plan For CollectingObjective EvidenceSection 4.1 GeneralRequirements (Scope)An EMS Scope has beendeveloped that clearly identifiesthe facilities/activities that aresubject to the provisions of theEMS.Locate and review EMS Scope.Section 4.2 EnvironmentalPolicyAn environmental policy hasbeen developed and signed bySenior Management.Locate and review writtenpolicy statement.The environmental policy hasbeen communicated to all EPAand on-site contractorpersonnel.Review records ofcommunications.Observe signage.The policy is available to thepublic.Identify and confirm method ofpublic disclosure.The policy is appropriate to thenature, scale, and environmentalimpacts of the facility’soperations.Review policy; determineconsistency with activities,products and services coveredby the EMS.The policy includes acommitment to continualimprovement of the EMS.Review policy; determineconsistency with EMS.The policy includes acommitment to pollutionprevention.Review policy; determineconsistency with EMS.The policy includes acommitment to regulatorycompliance.Review policy; determineconsistency with completion ofcompliance assessment(s).The policy provides aframework for setting andreviewing objectives andtargets.Review policy; determineconsistency with objectives andtargets.Facility maintains a documentedprocedure for identifyingenvironmental aspects.Review procedure.Procedures adequately coverenvironmental interactionsoccurring as a result of thefacilities activities, products,and services.Review lists of activitiesconsidered.The activities, products andservices of suppliers andInterview EMS Coordinator.EMS ElementSection 4.3.1 EnvironmentalAspectsUNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 7 of 14EMS ElementSection 4.3.2 Legal and OtherRequirementsSection 4.3.3 Objectives,Targets, and ProgramsAudit CriteriaSuggested Plan For CollectingObjective Evidencecontractors (used on site)considered in definingenvironmental aspects.Interview EMS Team Members.Procedures include theenvironmental aspectsassociated with changes in thefacilities operations (to includenew activities, products orservices, or non-routineoperations.)Review procedure.Interview EMS Coordinator.Procedure includes identifyingsignificant aspects based onreview of potential significantimpacts.Review procedure.Inventory of aspects is updatedperiodically.Review current/past aspectsinventory.Facility has established andmaintains a procedure toidentify legal and otherrequirements to which thefacility subscribes.Review procedure.Facility maintains a current listof applicable legal and otherrequirements.Review list of legal and otherrequirements.Other requirements have beendefined, if any exist.Interview EMS Coordinator.The facility has identified howlegal requirements apply to itsenvironmental aspects.Interview EMS Coordinator.Review EMS ManualManagement Programs (MPs)are in place to ensure thatobjectives and targets areaccomplished.Locate and review MPs;interview MP Leads.Objectives and targets havebeen set and are documented.Review EMS Manual.SEAs were considered in settingobjectives and targets.Compare O&Ts to list of SEAs.O&Ts are consistent with thepolicy.Compare O&Ts to policycommitments.Interview EMS Coordinator andreview communication.If views of interested partieshave been expressed, determineif they were considered insetting O&Ts.UNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 8 of 14EMS ElementSection 4.4.1 Resources, Roles,Responsibility, and AuthorityAudit CriteriaSuggested Plan For CollectingObjective EvidenceTechnological options,financial, operational, andbusiness requirements wereconsidered in setting O&Ts;targets are measurable wherepractical.Review meeting minutes.Review MPs.Facility has set performanceindicators for monitoring/measuring progress towardO&Ts.Interview EMS Coordinator.Review MPs.Objectives and targets areconsistent with commitment topollution prevention, continualimprovement and regulatorycompliance.Review O&Ts and policy.The facility has developedmanagement programs MPs forachieving O&Ts.Locate and review MPs.MPs designate responsibility forachieving O&Ts at eachrelevant level/function.Review MPs.MPs include means andtimeframes for completion.Review EMPs & SMPs.MPs include specific tasks andare maintained for newdevelopments.Review MPs and MPProcedure; procedure includesprocess to modify MPs toconform to new developments.MPs are effective for achievingO&Ts derived from legal andother requirements.Review MPs.Interview EMS Coordinator.EMS responsibilities have beenassigned, documented, andcommunicated.Review EMS documents andcorrespondence.A management representativehas been appointed by topmanagement.Review Roles andResponsibility appointmentmemos.Roles and responsibilities havebeen effectively implemented.Select 2 EMS Procedures andidentify lead responsibilities:interview responsibleindividuals.Resources have been providedby management to ensureimplementation and control ofInterview EMS Coordinator andSenior Staff members on theresources made available to theUNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 9 of 14EMS ElementSection 4.4.2 Competence,Training, and AwarenessSection 4.4.3 CommunicationAudit CriteriaSuggested Plan For CollectingObjective Evidencethe EMS.EMS.The facility has identified theEMS-related training needs ofits employees and on-sitecontractors.Interview EMS Coordinator.Awareness training has beenestablished and includesinformation on policy, EMSpurpose, employee’s roles.Review results of training needsanalysis.Awareness training has beenconducted for all employees.Review training records.Awareness training programaddresses:· importance of conformance toEMS· significant actual or potentialenvironmental impacts· roles and responsibilities forEMS implementation andmaintenance· potential consequences ofdeviations from EMS.Review awareness trainingdocuments and other materials.Interview staff members toverify success of trainingprogram.Employees performing taskswhich can cause significantimpact meet establishedcompetency criteria on the basisof education, experience ortraining.Interview EMS Coordinator.Interview select supervisorsrelating to establishing andmaintaining competency.Interview select individuals withEMS roles & responsibilities toassess competency; reviewcompetency training materialsand records.The facility has established andmaintains procedures forcommunicating informationregarding environmental aspectsand the EMS internally.Review procedure.Interview employees.The environmental policy hasbeen distributed to all Divisionemployees.Review bulletin boards, signage,etc.The facility has established andmaintains procedures forreceiving, documenting, andresponding to relevantReview procedures.Review external communicationemails, etc.UNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 10 of 14EMS ElementAudit CriteriaSuggested Plan For CollectingObjective Evidencecommunications from externalinterested parties.Section 4.4.4 DocumentationSection 4.4.5 Control ofDocumentsThe facility has made itsenvironmental policy availableto the public.Locate and review policy onpublic Web site.The organization has consideredexternal communication of itssignificant aspects and hasrecorded a decision to do it ornot.Interview EMS Coordinator.Review record of decision.The organization has establisheda procedure for communicatingwith suppliers and contractors.Review procedures in EMSManual.The facility has developed therequired EMS procedures or hasdeveloped appropriatejustification for why certainprocedures have not beencreated.Review EMS Manual.Interview EMS Coordinator.The organization has establishedand maintains information thatdescribes the core elements ofthe EMS and provides directionto related documentation.Review EMS Manual.The organization has establishedprocedures for controlling allEMS-required documents.Review procedure.Procedure provides for locatingEMS documents.Review procedure and identifydocuments to ensure in properlocation.Documents are periodicallyreviewed and revised byauthorized personnel.Review selected EMSDocuments.Procedure providesresponsibilities for creating andmodifying documents;procedure is followed.Review procedures – procedurespecifies retention periods forEMS documents; interviewEMS Coordinator.A process exists for removingobsolete documents from allpoints of issue and use or forpreventing their unintended use;process is followed.Review procedure; interviewEMS Coordinator.Appropriate EMS DocumentsInterview employees at targetedUNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 11 of 14EMS ElementAudit CriteriaSuggested Plan For CollectingObjective Evidenceare available at all locationswhere essential operations areperformed.locations; have themdemonstrate access.EMS Documents are legible,dated, identifiable, andmaintained in an orderlymanner.Review selected EMSdocuments - all EMS documentsare stored electronically.The facility has established andmaintains a documentedprocedure for establishing andmaintaining OperationalControls (OCs).Review procedure.OCs have been developed anddocumented, where appropriate,to manage activities, productsand services contributing toSEAs.Locate and review OCs;compare to list of SEAs.OCs have been implementedand are effective.Review records thatdemonstrate functioning ofoperational controls.Interview responsible operators.OCs were communicated toindividuals tasked withimplementing them.Identify employees whose jobsinvolve SEAs; interview.OCs stipulate operating criteriawhere appropriate.Review OCs.Section 4.4.7 EmergencyPreparedness and ResponseThis requirement has beendeferred to the various health &safety-related Regionalresponse plans.Review MFR documentingdeferral.Section 4.5.1 Monitoring andMeasurementThe facility has established andmaintains a documentedprocedure for monitoring andmeasuring the keycharacteristics of operations andactivities that can have asignificant impact on theenvironment.Review procedure.Monitoring, measuring, andcalibration requirements areappropriate for the organization.Review Monitoring, Measuring,Calibration, and ReportingTable; MPs; and OC MasterList.Required monitoring equipmentReview monitoring andSection 4.4.6 OperationalControlUNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 12 of 14EMS ElementSection 4.5.2 Evaluation ofComplianceSection 4.5.3 Nonconformity,Correction Action, andPreventive ActionSection 4.5.4 Control ofRecordsAudit CriteriaSuggested Plan For CollectingObjective Evidenceis calibrated and maintained.calibration records.A documented procedure hasbeen established and ismaintained for periodicallyevaluating the status ofcompliance with relevant legaland other requirements.Review procedure.Assessment Team membersmeet requirements specified inthe Assessment Procedure.Interview EMS Coordinator.Review training records.The findings and observationscontained in the AssessmentReport are evidence-based.Review Assessment Reports.The non-conformancesidentified in the AssessmentReport clear and include therequirement and evidence.Review Assessment Reports.Records of complianceassessments are maintained.Review assessment reports.The organization has establishedprocedures for definingresponsibility and authorities forhandling and investigating nonconformances, mitigatingimpacts, and initiating andcompleting corrective andpreventative actions.Review procedure.Corrective and preventativeactions are appropriate to themagnitude of the problems andresulting impacts.Review compliance assessment/ conformance audit MFRs fordisposition of findings andcorrective and preventive actionforms.Corrective and preventiveactions are implemented in atimely manner, address the rootcause(s), and are reviewed foreffectiveness.Review corrective andpreventive action forms.Changes in documentedprocedures resulting fromcorrective/preventative actionsare recorded.Review records of changes todocuments resulting fromcorrective/preventative actions.The organization has establisheda procedure for identifying,maintaining, and disposing ofReview procedure.UNCONTROLLED WHEN PRINTEDInterview EMS Coordinator.
EMS 1006.7210.13GAugust 11, 2014Page 13 of 14EMS ElementAudit CriteriaSuggested Plan For CollectingObjective Evidenceenvironmental records.Section 4.5.5 Internal AuditSection 4.6 ManagementReviewRecords are maintained oftraining activities.Review records.Records are maintained ofresults of audits and reviews.Review records.Records are legible, identifiableand traceable to the activity,product, or service involved.Review records.Records are retrievable.Observe process for retrievingrecords; review representativesample of measuring andmonitoring records.Records are retained inaccordance with establishedprotocol.Interview EMS Coordinator.The facility has establishedprocedures for conductingperiodic internal EMS audits.Review procedure.Audit frequency has beenspecified and adhered to.Review procedures.Audit requirements/criteria havebeen specified in the AuditPlans.Review Audit Plans.Audit Plans includeresponsibilities, scope, andmethodologies, including howresults will be reported.Review Audit Plans.Audit team members meetrequirements specified in theAudit Procedure.Review training records.The findings and observationscontained in the Audit Reportare evidence-based.Review Audit Reports.The non-conformancesidentified in the Audit Reportclear and include therequirement and evidence.Review Audit Reports.The facility has established aprocedure for managementreviews of the EMS.Review procedure.The management reviewprocedure specifies the types ofReview procedure.UNCONTROLLED WHEN PRINTED
EMS 1006.7210.13GAugust 11, 2014Page 14 of 14EMS ElementAudit CriteriaSuggested Plan For CollectingObjective Evidenceinformation and documents thatneed to be assembled and madeavailable.Management review addressespossible needs for changes inpolicy, objectives, or other EMSelements.Review procedure.Review minutes of managementreview meeting.Management review addressesthe possible impact of changingcircumstances on the EMS.Review minutes of managementreview meeting.Records/minutes ofmanagement reviews are kept.Review records of managementreview meeting; results frommanagement reviews arecommunicated to all Divisionemployees.UNCONTROLLED WHEN PRINTED
a. The Audit Scope will be determined by the EMS Coordinator as defined in the most current version of EMS 1006.5100.01. b. The Audit Schedule may be established by the EMS Coordinator, jointly by the Lead Auditor and the EMS Coordinator, or by the Audit Team at the discretion of the EMS Coordinator. c.
