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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
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.
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.
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.
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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.
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.
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.
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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.
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.
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• 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 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.
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
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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
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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.
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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
****************************************************************************
Significant Aspect
and/or Objective and
Target Measurement Measurement
Parameter(s) Procedure (s)
*******************************************************************************************
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)
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towards objectives and
targets
Calibration • Calibration records
************************************************************************
Mgmt. X X
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Maint. X X X X
Mill Mgr. X X X
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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
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.
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
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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.
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.
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:
The final audit report shall be submitted to the EMS Representative for
appropriate action.
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