Overview

This article provides practical advice and guidance for those tasked with gaining ISO 14001 certification for their organisation and complements the article, “Implementing an Environmental Management System (EMS) – a Consultant’s Viewpoint”.

If you are considering implementing an EMS, LRQA would advise you to consider the advice of both articles alongside the standards ISO 14001:2004 EMSs – Requirements with guidance for use; ISO 14004:2004 EMSs – General guidelines on principles, systems and support techniques; and ISO 19011:2002 Guidelines for quality and/or environmental management systems auditing, in order to gain a balanced perspective.

The ISO 14001 standard can be purchased from us by clicking on our Purchase Standards section.

This article has been written by Frances Stones who joined LRQA as an EMS Lead Assessor in January 2003 and has over 13 years environmental consultancy and auditing experience. Frances holds an Environmental Science degree from the University of Wales, Aberystwyth, an Environmental Law Masters degree from the University of Central Lancashire, is a Chartered Environmentalist, Full Member of IEMA and an IEMA Registered Principal Environmental Auditor.

Next | Last

Why should you implement an Environmental Management System?

“Implementing EMSs can assist organisations improve their resource efficiency and reduce bottom line costs. They can also help conformity with customer requirements in the supply chain, enable sustainable procurement policies, enhance an organisation’s reputation, secure new markets and help improve communication with employees, regulators, investors, and other stakeholders.”

DEFRA Position Statement on Environmental Management Systems, April 2008.

Everyone is aware of ‘the environment’. There are constant references in the media, politics and in the home. However, ‘the environment’ is such a widely used term that it can be tricky to describe.

The Oxford English Dictionary defines ‘environment’ as “the surroundings or conditions in which a person, animal, or plant lives or operates”, and ISO 14001:2004 defines ‘environment’ as “surroundings in which an organisation operates, including air, water, land, natural resources, flora, fauna, humans, and their interaction”. So, why should your business be interested in the environment?

All businesses are faced with risks which, if not identified and managed, may threaten their success. The ‘environment’ can present such business risks in relation to legal requirements, resource availability and cost, customer and consumer demands and even insurance costs and loss of reputation.

However, organisations should not only consider the negative risks from the environment. By developing an environmental management system businesses can find positive outcomes including more efficient use of resources, reduced utility costs, marketing opportunities, better regulatory compliance levels and even reduced regulatory costs.

An effective environmental management system (EMS) will enable your business to identify its strengths, weaknesses, threats and opportunities, which will in turn improve performance and reduce risk.

First | Previous | Next | Last

Why is ISO 14001 good for your business?

The EMS standard BS EN ISO 14001:2004 Environmental Management Systems – Requirements with guidance for use is the most popular model amongst a number of EMS standards including Eco-Management & Audit Scheme (EMAS) and BS EN16001. LRQA also offer PRiSM - your Progressive Route into Systems Management, which allows businesses with an existing ISO 9001 quality management system to implement ISO 14001 at their own pace through six independently assessed and certificated Steps.

ISO 14001, like most business management systems, is based on a Plan-Do-Check-Act cycle with continual improvement as a key driver. “Continual improvement” is defined by ISO 14001 and ISO 14004 (clause 3.2) as the “recurring process of enhancing the EMS in order to achieve improvements in overall environmental performance consistent with the organisation’s environmental policy”.

Environment Agency Position Statement, January 2005 “We formally recognise EMSs certified by UKAS-accredited bodies in our risk-based, approach to regulation through the OPRA (Operator and Pollution Risk Appraisal) scheme. This is because our studies prove that the documentation of an EMS makes it quicker and easier for us to regulate a site or company.”

First | Previous | Next | Last

Before you start with the standard

The theoretical benefits of an EMS may sound convincing, but what are the pitfalls when implementing an EMS? Some of the key difficulties are linked to management commitment and resource availability. Before you begin, your business must be fully committed to providing the necessary time and resources (personnel, financial, technical etc) for this project and without the full and continued support of the whole organisation, from top management to shop floor, you may not succeed.

Another snag encountered by many organisations is the use of overly-bureaucratic management system documentation. Remember to make your EMS user-friendly and practical. A few good procedures will be more effective than many poor ones.

To help you plan your project, we have developed an implementation planner; defining the typical stages and activities leading to certification. This also includes references to additional LRQA services which may be of assistance. You can view the EMS Implementation Planner here (amended version 2011 to be linked)

An initial environmental review (see clause 4.1.4 of ISO 14004) is the best way to establish the current position of your organisation; your baseline. This review should cover four key areas:

• Identification of the environmental aspects associated with your activities, products and services in the past, present and future. This includes those associated with normal, abnormal (e.g. start up/shut down) and emergency (unplanned) situations.
• Identification of applicable legal requirements and other requirements to which the organisation subscribes (trade associations, industry standards etc)
• Examination of existing business management practices and procedures; including those associated with procurement and contracting.
• Evaluation of previous emergency situations and incidents, complaints, adverse communications with Regulators etc.

The article “Implementing an EMS – A Consultant’s Viewpoint” refers in more detail to the information needed to complete your review.

First | Previous | Next | Last

Structure of ISO 14001

As previously mentioned ISO 14001 is based on the Plan, Do, Check, Act model and is structured into five distinct sections:

• General Requirements (clause 4.1) and Environmental Policy (clause 4.2)
• Planning (clause 4.3) PLAN
• Implementation & Operation (clause 4.4) DO
• Checking (clause 4.5) CHECK
• Management Review (clause 4.6) ACT

This ongoing process will allow your organisation to continually improve the EMS, improve your overall environmental performance and reduce your business risks.

This article will take each section in turn and give practical advice on the requirements contained in the standard, along with advice on implementation and examples of weaknesses that are routinely identified during certification assessments.

First | Previous | Next | Last

General requirements (clause 4.1) & Environmental policy (clause 4.2)

General requirements (clause 4.1)

“The organisation shall establish, document, implement, maintain and continually improve an EMS in accordance with the requirements of this International Standard and determine how it will fulfil these requirements. The organisation shall define and document the scope of its EMS.” ISO 14001:2004 (clause 4.1).

The general requirement is very simply stated and requires that the EMS is implemented and maintained in order to achieve continual improvement. The scope of the EMS must also be documented, and is typically expected to be more detailed than the scope recorded on an accredited certificate. The scope should allow anyone reading it to understand the coverage of the organisation’s activities, products and services within the EMS.

Assessment Weaknesses

Commonly encountered problems include:

• Inadequately defining the scope of the organisation (too vague)
• Failing to document the scope of the EMS
• Inadequate resources provided to establish, implement and maintain the EMS.

First | Previous | Next | Last

Environmental Policy (clause 4.2)

The Environmental Policy is the only part of your EMS which must be freely available to the public and it must be endorsed by the organisation’s top management. The Policy must also include a commitment from the organisation to three key principles:

• pollution prevention
• compliance with legal and other requirements
• continual improvement

Clause 3.18 of ISO 14001 and clause 3.22 of ISO 14004 define prevention of pollution as, “use of processes, practices, techniques, materials, products, services or energy to avoid, reduce or control (separately or in combination) the creation, emission, or discharge of any type of pollutant or waste, in order to reduce adverse environmental impacts. NOTE Prevention of pollution can include source reduction or elimination, process, product or service changes, efficient use of resources, material and energy substitution, reuse, recovery, recycling, reclamation and treatment”.

An EMS which has been well implemented and maintained in accordance with the requirements of ISO 14001 will deliver these policy commitments. However, it is important to remember that LRQA will assess against all documented policy commitments and a failure to demonstrate compliance with a policy commitment is a failure to comply with ISO 14001 and may therefore preclude certification.

The environmental policy may be a stand-alone document or combined with other policies such as Quality or Health and Safety.

Assessment Weaknesses

Commonly encountered problems include:

• Generic policy statements which could be applicable to any organisation and do not reflect the nature, scale and environmental impacts of the business.
• Inclusion of unachievable or unsubstantiated claims in the Policy, for example to achieve “zero waste generation” or to “go beyond legal requirements”.
• Lack of mechanism to make the policy available to the public and to all persons working for, or on behalf of, the organisation.
• Commitment to legal requirements but no mention of ‘other’.

First | Previous | Next | Last

Planning (clause 4.3)

Environmental aspects (clause 4.3.1)

It is important that this clause is fully understood and implemented correctly as the rest of the clauses of ISO 14001 are linked to these environmental aspects.

It is important not to confuse activities with aspects. An environmental aspect is defined in clause 3.6 of ISO 14001 as an “element of an organisation’s activities or products or services that can interact with the environment”. Examples include trade effluent, air emissions, energy use, raw materials use, noise etc.

An environmental impact is defined in clause 3.7 of ISO 14001 as “any change to the environment, whether adverse or beneficial, wholly of partially resulting from an organisation’s environmental aspects”. Examples include water pollution, air pollution, depletion of natural resources (fossil fuel, aluminium etc), noise pollution etc.

There is no specified approach for the identification of environmental aspects and impacts or for determining their significance. Each organisation should develop an approach that is appropriate to its scope, nature and scale. The process for aspects identification used by a nuclear power station is unlikely to work well for a firm of architects!

Identification of aspects, impacts and significance evaluation can be quite subjective and many organisations find it useful to use a team to establish an effective, repeatable process. The use of process-flow diagrams to identify the inputs and outputs of activities, products and services can also be useful.

Once initial aspects have been identified it is also important that you consider the mechanism for ongoing review and updating of aspects i.e. management of change. Clause 4.3.1 (a) includes the requirement to take “into account planned or new developments, or new or modified activities, products and services”. This can include purchasing of new equipment, changing existing processes, extending working hours etc

Assessment Weaknesses

Commonly encountered problems include:

• Failure to evaluate the significance of an aspect under normal, abnormal and emergency operating conditions
• Failure to identify the aspects of design processes (where applicable)
• Failure to identify the aspects of products (including positive environmental aspects e.g. if you manufacture energy efficient motors)
• Failure to consider off-site sub-contract activities e.g. 3rd party plating operations, e.g. 3rd party transport company.
• Failure to identify environmental issues associated with changes e.g. Environment Agency permit variation required when modifying existing processes, e.g. new discharges associated with new plant etc.
• Failure to determine significance
• Evaluation of activities rather than aspects

First | Previous | Next | Last

Legal and other requirements (clause 4.3.2)

This is usually the most daunting part of the standard for most organisations due to the sheer volume of environmental legislation that exists! As part of the initial environmental review you should identify the environmental legislation that is applicable to your organisation and ascertain what you must do to ensure your ongoing compliance.

There are numerous mechanisms by which to identify legal requirements and can include subscription to legal update services and or environmental publications, use of specialist legal consultants, web searches and use of sites such as The Environment Agency’s website – Net Regs, discussions with Trade Associations etc.

It is important to also ensure that you identify those “other requirements to which the organisation subscribes related to its environmental aspects” (clause 4.3.2 of ISO 14001) e.g. trade association environmental commitments (FHC) e.g. customer requirements (BRC) e.g. head office requirements (corporate policy) etc.

The standard also requires that you determine how these legal and other requirements apply to your environmental aspects (clause 4.3.2(b)) i.e. demonstrate the linkage between specific aspects and specific legal and other requirements.

Assessment Weaknesses

Commonly encountered problems include:

• A lack of understanding of exactly how each piece of legislation (or other requirements e.g. BRC, customer requirements) is applicable to the organisation’s activities, products or services.
• A lack of understanding of what permits, documentation or other evidence is required to ensure compliance.
• Printing out copies of legislation, but with no understanding of what parts of the hundreds of pages are relevant!
• Failure to identify relevant ‘other requirements’
• Failure to link specific aspects with specific legal and other requirements
• Once the initial review of legal and other requirements has been completed, the organisation fails to keep up to date with changes in legal or other requirements e.g. new legislation e.g. new customers e.g. new T&C.

First | Previous | Next | Last

Objectives, targets and programmes (clause 4.3.3)

Objectives and targets should fulfil the commitments established in the environmental policy and improve environmental performance. Setting and achieving objectives is one means of establishing continual improvement, which is at the heart of achieving and maintaining ISO 14001.

When setting objectives and targets the organisation should take into account, and consider a number of factors:

• legal requirements
• other requirements to which the organisation subscribes
• significant environmental aspects
• technological options
• financial requirements
• operational requirements
• business requirements
• the views of interested parties

Organisations should ensure that they are clear about the definitions of objectives, targets and management programmes within ISO 14001.

An environmental objective is defined by clause 3.9 as an “overall environmental goal, consistent with the environmental policy that an organisation sets itself to achieve” e.g. Improve energy efficiency.

An environmental target is defined by clause 3.12 as a “detailed performance requirement, applicable to the organisation or parts thereof, that arises from the environmental objectives and that needs to be set and met in order to achieve those objectives” e.g. Reduce consumption of electricity (kWh) per tonne of product by 5% of 2010 baseline figures by the end of 2011. Targets should be specific, measurable, achievable, relevant and timed (SMART) whenever practical.

Programmes must also be established, implemented and maintained to enable your organisation to meet these targets and ultimately achieve its objectives. Programmes must include:

• designation of responsibility for achieving objectives and targets at relevant functions and levels of the organisation, and
• the means and,
• timeframe by which they are to be achieved.

Management programmes should be reviewed at regular and planned intervals and should be dynamic; adapting to changes to business processes, activities, products or services. Sometimes realistic objectives and targets can become unrealistic and in these situations management must identify this and change their objectives, targets and programmes accordingly.

Assessment Weaknesses

Commonly encountered problems include:

• Failing to set SMART objectives or targets
• Failing to assign responsibilities to specific people at various levels and functions of the organisation e.g. every action is on the Environmental Manager
• Setting too many objectives and failing to manage them.
• Failing to develop management programmes or failing to keep management programmes up to date.

First | Previous | Next | Last

Implementation and operation (clause 4.4)

Resources, roles, responsibilities and authority (clause 4.4.1)

The key requirement of this clause relates to the obligation that “Management shall ensure the availability of resources essential to establish, implement, maintain and improve the EMS.”

As stated earlier, if the top management of your business are not fully committed to providing the necessary “human resources, specialised skills, organisational infrastructure, technology and financial resources” for this project then it may not succeed.

It is also crucial to have the full and continued support of the whole organisation, from top management to shop floor. It is an organisation that implements an effective EMS, not just one Environmental Representative.

A member of top management should accept ultimate responsibility for the EMS implementation and maintenance and typically this is the environmental policy signatory.

In addition, a “specific management representative” should also be appointed to ensure the EMS is established, implemented and maintained. The environmental management representative (EMR) will also be responsible for reporting to top management on performance of the EMS and for making recommendations for improvement. The EMR may be one person or more than one person, but in all instances these roles must be clearly “defined, documented and communicated”.

Other key roles, responsibilities and authorities should also be “defined, documented and communicated” e.g. environmental auditors, environmental champions, waste managers etc.

It is important to remember that the typical organisational management and reporting structure of your business may not match the EMS management and reporting structure.

Assessment Weaknesses

Commonly encountered problems include:

• Inadequate provision of resources e.g. insufficient internal auditors or insufficient time allowed for auditors to conduct audits (work pressures)
• Inadequate authority of the EMR e.g. Environmental Advisor not given management authority on a level with other management functions such as Maintenance Manager, Shift Manager, Procurement Manager etc
• Inadequate documented, definitions of key roles and responsibilities

First | Previous | Next | Last

Competence, training and awareness (clause 4.4.2)

The organisation must ensure that all persons “performing tasks for it or on its behalf” that can impact on the environment must be “competent on the basis of appropriate education, training or experience, and shall retain associated records”. Persons performing tasks for on or behalf of the organisation include employees, agency staff, temporary staff, contractors, consultants etc.

It is therefore important that your organisation has effective processes to identify when any of these persons are performing a task that can have an environmental impact. These processes may be different for employees e.g. training skills matrix than other persons e.g. contractors permit to work system.

Once these situations have been identified your organisation must then ensure that adequate training is provided to fill any competency shortfalls or otherwise ensure records are retained as proof of competency. It should also be noted that competency is not always the same thing as training or qualifications!

In addition, all persons working for the organisation must at the very least be made aware of:

• The importance of conformity with the environmental policy and procedures and with the requirements of the EMS
• The significant environmental aspects and related actual or potential impacts associated with their work and the benefits of improved personal performance
• Their roles and responsibilities in achieving conformity with the requirements of the EMS, and
• The potential consequences of departure from specified procedures

LRQA offer a range of suitable training courses, including public and in-company training options that can be tailored to suit your organisation’s needs. For more information View the EMS Implementation Planner here.

Assessment Weaknesses

Commonly encountered problems include:

• Inadequate competency of environmental representative (EMR) e.g. limited environmental training / knowledge
• Inadequate competency of internal auditors e.g. quality auditors used to conduct EMS audits with no cross-training
• Failure to capture Agency and Temporary staff or Contractors effectively
• Failure to continue to update and refresh environmental awareness training for all employees after initial certification visit
• Failure to retain adequate records as proof of training or competency
• Failure to define competencies of persons performing tasks that have the potential to cause significant environmental impact

First | Previous | Next | Last

Communication (clause 4.4.3)

This clause requires a process for “internal communication among the various levels and functions of the organisation”. This internal communication should be both ‘top down’ and ‘bottom up’; ensuring the involvement of the whole organisation in the implementation and improvement of the EMS. Common examples include minutes of meetings, environmental bulletins, emails, suggestion boxes, notice boards, newsletters and cross-functional working groups.

This clause also requires a process for “receiving, documenting and responding to relevant communication from external interested parties”. Such ‘interested parties’ may include regulators, customers, trade associations, neighbourhood groups etc. It may be that the process changes, depending on which interested party is communicating e.g. request for environmental information from a customer may go via the Quality Manager and an investigation letter from a regulator for an environmental incident may go via the MD or Company Secretary.

Another key requirement relates to the decision which your organisation must make about whether or not “to communicate externally about…significant environmental aspects”. This decision can either be ‘always yes’, ‘always no’ or ‘on a case-by-case basis’. In reality it may be difficult to agree to always communicate your significant environmental aspects externally as you may not wish to share this information with a competitor or eco-activists! It may also be difficult to agree to never communicate your significant environmental aspects externally as you are unlikely to refuse this request if it came from a valued customer or a regulator.

Whatever your business agrees in relation to external communications it is important that the organisation “documents its decision”. This is typically recorded in management review minutes or in a documented procedure. If the decision is to communicate then your organisation must also “establish and implement a method(s) for this external communication”.

Assessment Weaknesses

Commonly encountered problems include:

• Inadequate mechanism in place for dealing with external environmental communications when the Environmental Management Representative is on holiday, working off site or ill
• Failure to document the organisation’s decision regarding external communication of significant environmental aspects.
• Failure to establish an effective process for external communication.

First | Previous | Next | Last

Documentation (clause 4.4.4) & Control of documents (clause 4.4.5)

These clauses set out the types of documentation that your EMS must include and also the mechanism to ensure such documents are adequately controlled.

Within ISO 14001 there are very few requirements for documented procedures, but the following key things must be documented:

• Environmental policy
• Objectives & targets
• Scope of the EMS
• Description of the main elements of the EMS & their interaction (including reference to related documents)

Documentation may be in paper or electronic form and may take the form of words, pictures, photographs or flow charts.

The majority of organisations develop a four-tier structure for EMS documentation: Manual, Procedures, Work Instructions and Forms. However, this is not a specific requirement of the standard and your organisation is free to develop whatever structure works best for you.

Whatever documentation structure you develop it is important to ensure that there is a “description of the main elements of the EMS and their interaction, and reference to related documents” contained within it.

Adequate document control (clause 4.4.5) ensures that documented procedures are correct, up to date and available to those who need them. Key requirements of this clause include the need to “ensure that changes and the current revision status of documents are identified” and “prevent the unintended use of obsolete documents”.

Clause 4.4.5(f) also requires that your organisation identifies and controls “documents of external origin” e.g. Environment Agency Permit, Planning Permission letters, water company discharge consents, COMAH inspection documents, Consultant air monitoring report etc. Distribution of these documents must be effectively controlled e.g. up to date versions available in relevant areas and obsolete versions archived etc.

Assessment Weaknesses

Commonly encountered problems include:

• Inadequate ‘index’ to allow users to navigate through the EMS documentation to find the right information
• Too much information and duplication of documentation. This is particularly a problem for electronic systems where it is easy to generate new documents, files and folders, but archiving or deleting of documents is much less prevalent!
• Lack of document control e.g. not updating procedures with personnel or process changes,not including revision status, not removing obsolete documents.
• Not developing a robust mechanism for control of “documents of external origin” e.g. old versions of discharge consents displayed in effluent plant.

First | Previous | Next | Last

Operational control (clause 4.4.6)

This clause has the biggest influence over the day-to-day operation of your business and relates to the processes, procedures, work instructions etc that you use to manage the environmental risks associated with your activities, products and services.

ISO 14001 only requires “documented procedure(s)” when their absence could risk non-compliance. In theory this means that other than those documents required by clause 4.4.4, your EMS can have no documented procedures and still conform to the requirements of ISO 14001. However, in practice, most organisations have some documented operational control procedures.

As stated earlier, it is important to avoid overly-bureaucratic management system documentation to keep your EMS user-friendly and practical. A few good procedures will be more effective than many poor ones.

Clause 4.4.6 requires that your organisation identify “those operations associated with the identified significant environmental aspects” and ensure that those operations are sufficiently planned and “carried out under specified conditions” to minimise the environmental risk associated with the activity.

Effective operational controls should ensure compliance with legal and other requirements and policy commitments, drive continual improvement, prevent pollution, manage significant environmental aspects, achieve business objectives and reduce environmental risks.

A specific requirement of clause 4.4.6(c) relates to controlling the “environmental aspects of goods and services used by the organisation” and requires “applicable procedures and requirements” to be communicated to suppliers and contractors. This is a key area of operational control as the activities of contractors and suppliers often represent a greater environmental risk than those associated with internal personnel.

There is also a linkage between competency, training and awareness (clause 4.4.2) and effective operational controls. LRQA offer a range of suitable training courses, including public and in-company training options that can be tailored to suit your organisation’s needs. For more information View the EMS Implementation Planner here.

Assessment Weaknesses

Commonly encountered problems include:

• Inadequate control of contractors in relation to environmental risk e.g. permit to work system does not include any controls of contractor waste e.g. environmental competencies of air conditioning contractors not considered
• Not considering off-site suppliers & contractors e.g. off-site plating activities
• Lack of knowledge of relevant procedures amongst employees
• Too many procedures & conflicting requirements of different procedures.

First | Previous | Next | Last

Emergency preparedness (clause 4.4.7)

Potential emergency situations should have been identified as part of your initial aspects evaluation (clause 4.3.1) and now clause 4.4.7 requires your organisation to outline “how it will respond to them” in order to “prevent or mitigate associated adverse environmental impacts”. Remember that an emergency situation is purely something that you did not mean to happen and may not involve emergency services or specialist trained teams on site to deal with. Linked with this is the need to have a full understanding of the foul and surface water drainage of your organisation (internally and externally).

These emergency preparedness procedures must also be periodically reviewed and revised “in particular, after the occurrence of accidents or emergency situations”. The organisation must “also periodically test such procedures where practicable” and can use real accidents and emergency situations to meet this requirement. If there have not been such accidents or emergency situations, then a test may be conducted in a number of ways e.g. verbal questioning of operators and recording responses (audit), e.g. physical simulation (with non-damaging substance such as water), e.g. desk top simulation (COMAH simulations) etc.

Assessment Weaknesses

Commonly encountered problems include:

• Failure to identify a potential or actual emergency situation e.g. incorrect drainage plan
• Failure to schedule and complete periodic tests of emergency procedures
• Failure to effectively analyse the results of actual accidents or emergency situations and drills
• Provision of inadequate training for those required to deal with emergency situations.

First | Previous | Next | Last

Checking (clause 4.5)

Monitoring & Measurement (clause 4.5.1)

The organisation must ensure it has a systematic process “to monitor and measure, on a regular basis, the key characteristics of its operations that can have a significant environmental impact”. Once again the standard references the significant impacts identified under clause 4.3.1 and requires that regular checks are made against these areas of environmental business risk. This clause also requires that monitoring results be documented.

Key areas for monitoring include those associated with objectives and targets e.g. energy consumption; those associated with legal compliance e.g. Environment Agency Permit air emissions, Utility company discharge consent conditions; and those associated with compliance against other requirements e.g. corporate reporting (CSR, Sarbanes Oxley) etc.

Wherever possible, the equipment used for monitoring and measurement must be “calibrated or verified” and “associated records” of this calibration or verification must be retained by the organisation.

Assessment Weaknesses

Commonly encountered problems include:

• Not monitoring against all the legal limits set by effluent discharge consents, EA permits etc
• No calibration records are obtained for environmental monitoring equipment (particularly when monitoring conducted by 3rd party consultants)
• No review of monitoring results to determine compliance, trends & improvement opportunities.

First | Previous | Next | Last

Evaluation of compliance (clause 4.5.2)

This is a commonly misunderstood clause of ISO 14001, but it is critical to demonstrating that you are meeting your policy commitment to “comply with applicable legal requirements and with other requirements to which the organisation subscribes” (clause 4.2(c)).

Within ISO 14001 there are six key areas concerned with “compliance” which follow the plan-do-check-act business management system principal:

• POLICY - Environmental policy commitment to comply with legal and other requirements (clause 4.2).
• PLAN - The obligation to identify those legal and other requirements applicable to your organisation and which you must comply with (clause 4.3.2).
• DO - Operational controls (clause 4.4.6) which ensure that your day to day activities are conducted in line with identified legal and other requirements (so that there is no “deviation from the environmental policy”)
• CHECK - Monitoring and measurement results (clause 4.5.1) which include results of the organisations performance against legal and other requirements e.g. effluent analysis, stack monitoring, waste returns etc
• CHECK - Evaluation of compliance (clause 4.5.2) which is the review of the 4.5.1 monitoring records (e.g. effluent analysis) & 4.4.6 operational control records (e.g. waste transfer notes) against the legal and other requirements identified by 4.3.2 to determine whether or not your organisation meets the policy commitment to comply with legal & other requirements detailed in 4.2.
• ACT – Management review (clause 4.6) requirement to review the results of “evaluations of compliance with legal requirements and with other requirements to which the organisation subscribes”.

As you can see, there is a significant link between monitoring and measurement (clause 4.5.1) and evaluation of compliance (4.5.2) and indeed an earlier version of ISO 14001 (in 1996) incorporated both requirements in one clause 4.5.1. However, due to the general misunderstanding of the compliance evaluation requirement the current (2004) version of ISO 14001 gives this key requirement its own clause 4.5.2.

In a large number of organisations the evaluation of compliance (4.5.2) requirement is also linked with the internal audit process (4.5.5). However, audits usually involve limited ‘samples’ of records and operational controls. The compliance evaluation must be a more robust review of the evidence required to demonstrate compliance. Clause 4.5.2 specifically requires that “records of the results of the periodic evaluations” be kept by the organisation. The compliance evaluation must include sufficient documented “records” of the objective evidence reviewed to determine the level of compliance achieved and a “result” of the evaluation should be included i.e. compliant or not compliant.

Whilst the standard does not require a documented procedure for compliance evaluation, this is a complicated process and the majority of organisations define their mechanism for compliance evaluation in a documented procedure.

It should also be noted that the process for evaluation of compliance against legal requirements (clause 4.5.2.1) is often different to the process for evaluation of compliance against other requirements (clause 4.5.2.2) e.g. customer requirements.

Assessment Weaknesses

Commonly encountered problems include:

• No compliance evaluation is recorded against “other requirements”.
• Not conducting periodic compliance evaluation against all identified legal requirements
• Misunderstanding of clause 4.5.2 and incorrect belief that just updating the legal register (4.3.2) meets the requirements of compliance evaluation
• Insufficient documented “records” of the objective evidence reviewed to determine the level of compliance achieved e.g. reviewed “A N Other Water Labs Ltd" analysis of effluent sample 30/03/11.
• No statement of the level of compliance achieved e.g. fully compliant against the requirements of trade effluent discharge consent M289762 etc.

First | Previous | Next | Last

Nonconformity, corrective action and preventive action (clause 4.5.3)

Clause 4.5.3 requires organisations to identify, investigate and correct nonconformities. Clause 3.15 of ISO 14001 defines nonconformity as “non-fulfilment of a requirement”. The requirement that is not being fulfilled may relate to system performance e.g. failure to meet an ISO 14001 requirement. Or the requirement not being fulfilled may relate to environmental performance e.g. failure to meet an internal energy reduction target, e.g. failure to meet a legal emission limit. In some organisations internal performance and system performance deficiencies are termed ‘nonconformities’ and legal deficiencies are termed ‘non-compliances’.

The majority of “actual” nonconformities are identified through internal audits and compliance evaluations, but may come from a number of sources e.g. complaints, incidents, external audits, monitoring results etc. In addition, “potential” nonconformities should be identified wherever possible e.g. trend analysis, e.g. HAZOP etc.

Once actual or potential nonconformities have been identified the organisation is responsible for investigating and “determining their causes” i.e. root cause analysis. Once the root cause has been determined appropriate corrective and preventive actions must be implemented to “avoid their recurrence” or “avoid their occurrence”. These actions must be “appropriate to the magnitude of the problems and the environmental impacts encountered”.

Clause 3.17 defines preventive action as “action to eliminate the cause of a potential nonconformity” and clause 3.3 defines corrective action as “action to eliminate the cause of a detected nonconformity”.

Another key requirement of clause 4.5.3 is that of “reviewing the effectiveness of corrective actions and preventive actions taken”. Many organisations identify nonconformities, investigate them and implement corrective & preventive actions, but do not periodically review the corrective & preventive actions to ensure that they were effective in fully addressing the issue. In these instances nonconformities can then re-occur.

Assessment Weaknesses

Commonly encountered problems include:

• Inadequate root cause analysis (4.5.3(b))
• Failure to identify preventive actions, only corrective actions
• Failure to review the effectiveness of corrective & preventive actions (4.5.3(e))
• Only capturing audit nonconformities within the EMS, not other nonconformities e.g. compliance evaluation nonconformities, complaints, incidents, external audits etc.

First | Previous | Next | Last

Control of records (clause 4.5.4)

There is often confusion between documents and records. Clause 3.20 of ISO 14001 defines a record as a “document stating results achieved or providing evidence of activities performed”. A key characteristic of a record is that it is permanent and usually not revised. For example Noise Monitoring form F21, Rev 2 is a document, but once the form has been completed by the operator on a specific day it then becomes an individual record.

It is important to ensure that records “remain legible, identifiable and traceable” and to establish a procedure for the “identification, storage, protection, retrieval, retention and disposal of records”. This is particularly important now that most management systems contain electronic records.

Key records may include those relating to:

• Legal compliance e.g. air monitoring results, effluent analysis results, duty of care documentation etc
• Nonconformities, corrective & preventive actions
• Audit results
• Management review
• Training
• Calibration

Assessment Weaknesses

Commonly encountered problems include:

• In ability to retrieve key records
• Illegible records e.g. duty of care carbon copies
• Not keeping records for legally required retention times e.g. three years for waste consignment notes.

First | Previous | Next | Last

Internal audit (clause 4.5.5)

Internal audits are a key way for your organisation to identify actual and potential nonconformities and opportunities for improvement. The more effective your internal audit process, the more effective your EMS will be at managing your environmental business risks.

The results of the internal audits will be communicated to top management and can help to determine whether or not the EMS is suitable, adequate and effective.

An “audit programme(s)” must be developed, based on the “environmental importance of the operations concerned” (see aspects & impacts clause 4.3.1) and the “results of previous audits”. ‘Process’ audits are an effective way to audit against a number of internal procedures, ISO 14001 clause requirements and legal requirements and should be considered by your organisation. In particular, ‘process audits’ can be effectively integrated with other standards e.g. OHSAS 18001 & ISO 9001.

Internal audits must check conformance against internal processes & procedures and also against the requirements of ISO 14001. It is particularly important that the audit criteria, scope and methods are determined to avoid duplication and maximise the benefit of each audit. Auditors must also be competent, objective and impartial.

There is a linkage between competency, training and awareness (clause 4.4.2) and effective internal auditors. LRQA offer a range of suitable training courses, including public and in-company training options that can be tailored to suit your organisation’s needs. For more information view the EMS Implementation Planner here.

ISO 19011:2002 provides additional guidance on the management of audit programmes, the conduct of internal audits and competence of auditors.

Assessment Weaknesses

Commonly encountered problems include:

• Internal audit programme not based on environmental importance of the operations and results of previous audits
• Auditing only covers internal EMS procedures and not clauses of ISO 14001 and not key processes without documented procedures e.g. maintenance.
• Insufficient objective evidence detailed in the audit report, criteria and scope to determine what was covered by the audit
• Inadequate competency of internal auditors e.g. quality auditors used to conduct EMS audits with no cross-training
• Audits not being completed according to programme due to inadequate provision of resources e.g. insufficient internal auditors or insufficient time allowed for auditors to conduct audits (work pressures)
• No nonconformities being identified by internal audits due to inadequate authority of the internal auditors resulting in a fear to raise nonconformities against other managers.

First | Previous | Next | Last

Management review (clause 4.6)

This is the last clause of ISO 14001 and represents the final step in the Plan-Do-Check-Act process: that of taking action to continually improve the performance of the EMS. The key requirement of the Management Review process is for top management to review the EMS to “ensure its continuing suitability, adequacy and effectiveness”.

Clause 4.6 outlines the inputs which must be included in the management review:

• Follow-up actions from previous management reviews
• Changing circumstances including changes to aspects and legal & other requirements
• External communications including complaints
• Extent to which objectives & targets have been met
• Results of internal audits
• Results of evaluations of compliance with legal & other requirements
• Status of corrective & preventive actions
• Environmental performance of the organisation
• Recommendations for improvement

It is important to ensure that the outputs from the management reviews are recorded and that conformance against all (a) to (h) requirements of clause 4.6 can be demonstrated. However, not all (a) to (h) requirements must be carried out at the same time and the management review process can be spread out at “planned intervals”.

Clause 4.6.2 of ISO 14004 gives additional guidance on continual improvement and opportunities for improvement.

Assessment Weaknesses

Commonly encountered problems include:

• Inputs to management review are recorded, but outputs (i.e. comments & decisions of top management) are not recorded
• Results of evaluation of compliance not included in management review
• Recommendations for improvement not included in management review
• Environmental performance of the organisation not included in the management review. Environmental performance is defined in clause 3.10 and represents a summary conclusion as to the “measurable results of an organisation’s management of its environmental aspects” taking into account compliance levels, complaints, incidents, audit results, extent to which objectives and targets have been met etc.
• Management review does not actually determine whether or not the EMS is suitable, adequate and effective at managing the businesses environmental risks.

First | Previous | Next | Last

Conclusion

An effective EMS will enable your business to identify its environmental strengths, weaknesses, threats and opportunities, which will in turn improve performance and reduce risk.

“Defra believes that putting in place an environmental management system can help organisations openly demonstrate their responsibilities to their customers, investors, stakeholders, and clients and achieve regulatory benefits as well as secure improved efficiencies, and contribute to national efforts to reduce carbon emissions.”, DEFRA Position Statement on EMS’s, April 2008.

The overall aim of ISO 14001 is to “support environmental protection and prevention of pollution in balance with socio-economic needs”. Our ISO 14001 certification provides credibility for you and assurance for your stakeholders through the globally recognised LRQA brand.

LRQA has been involved in certification to ISO 14001 since it was first introduced in 1996. This article should provide an insight into the main elements of the standard that are required to be implemented to gain certification and some of the weaknesses that have been encountered during the assessment process.

To help your organisation meet today’s challenges, we are continuing to enhance our services and the way in which we carry out assessments. We don’t just verify that systems meet the requirements of ISO 14001. We go one step further by providing ‘added value’ beyond what you would expect from a traditional assessment process. This enhanced emphasis is embodied in the approach that we call ‘Business Assurance’.

For information on gaining PRISM, EMAS or ISO 14001 certification with LRQA, visit our Environment section.

LRQA also provide a number of engaging Environmental courses. Visit the training section to learn more.

To learn more about LRQA products and services, contact our business advisors on 0800 783 2179.

First | Previous

To learn more about LRQA products and services, contact our business advisors on 0800 783 2179

Page last modified on 18 April 2011

Article can be found online at:
http://www.lrqa.co.uk/help/Implementation/ems/lrqaguidance/

Care is taken to ensure that the information herein is accurate and up-to-date. However, LRQA accepts no responsibility for inaccuracies in, or changes to, such information.

The Lloyd’s Register Group comprises charities and non-charitable companies, with the latter supporting the charities in their main goal of enhancing the safety of life and property for the benefit of the public and, ultimately, the environment. Lloyd's Register and LRQA are trading names of the Lloyd's Register Group of entities. Services are provided by members of the Lloyd’s Register Group. For further details please see http://www.lr.org/entities © LRQA 2012 . All rights reserved.