universiti putra malaysia ems i nternal a udit w orkshop 3 a pril 2015 9.00 am – 5.00 pm...

UNIVERSITI PUTRA MALAYSIAEMS INTERNAL AUDIT

WORKSHOP3 APRIL 2015

9.00AM – 5.00PM

Facilitator : Hafriazhar Mohd. Mokhtar

Email : [email protected]

Mobile : +6019 258 5819

Climate Plus Sdn Bhd (805925-K)H-40-1A, Jalan Prima Saujana 2D,

Prima Saujana, 43000 Kajang, Selangor.climateplusmy.weebly.com

DELEGATIONS: QUALIFIED INTERNAL AUDITOR IN

ISO 14001:2004 EMS(REF.: UPM/ISO-EMS/P004; SEMAKAN 00; ISU 01;

15/7/2013)

OBJECTIVES:TO PROVIDE INTERNAL AUDITORS

WITH IMPROVED KNOWLEDGE AND TOOLS TO BE ABLE TO AUDIT AN IS0-

14001 ENVIRONMENTAL MANAGEMENT SYSTEM (EMS)

SUFFICIENTLY.

AGENDA OVERVIEW:

• Auditing

• IS0 14001 Framework

• EMS Principles

• EMS Internal Auditing

AUDITING

AUDITING

WHAT IS AUDITING?

Audit definition UNI EN ISO 19011 Ed. 2003: “Systematic, independent and documented process for obtaining audit evidence and evaluate objectively, in order to determine the extent to which audit criteria are fulfilled”.

Objectives of an Audit:

To achieve confidential knowledge of the conformity of the applied system by the organization that is object of evaluation, respecting the environment and conformity legislation.

AUDITING

WHO DO THE AUDIT?

Auditor definition: “Person with the competence to conduct an audit” (ISO 9000:2000. 3.9.9)

Audit team:

Also called a verification group, composed of an Audit Team Leader (Lead Auditor) as person in charge and assigned with a role of guidance of team member and reporting to auditee. In addition to this role, the team may also be composed of other figures identified as: audit team member (auditor), technical expert and observer.

AUDITING

TYPES OF AUDIT•Internal audits (or first party) carried out with the aim of verification of the accomplishment and effectiveness of the systems or some important aspects, like: particular operations, products and services, departments or functions of an organization.

•External audit (second party) audits carried out by an organization on its supplier/contractor (Client-Supplier relationship) using, in this case too, either internal personnel, usually an inter-functional team, or external society is entrusted with doing it.

•Certification audit (third party) independent of an organization, that has an aim release of the certificate of conformity with the requirements taken as a reference, that may be management systems.

AUDITING

Scope of an audit:

Audits carried out in an organisation, (they can be of the 1st, 2nd or 3rd party), have as a main scope judgement, through sample method, of the conformity of the implemented management system with the established requirements

ISO 14001

FRAMEWORK

ISO 14001 FRAMEWORKHERE WE

ARE!

EMS PRINCIPL

ES

EMS PRINCIPLES

ISO 14001 promotes these values:

•Think prevention before cure or correction•Environmental performance is everyone’s responsibility•Improving awareness and understanding helps to improve performance•Top Management must lead by example•Environmental management is risk management•Continual improvements never ends•In a system, everything depends on everything else (so does everyone)

EMS PRINCIPLES

So what is ISO 14001 about?

•It is a management framework to raise awareness and institute actions throughout the organization

•That makes environmental care a natural part of everyone's job

•In time, it develops an environmental culture just like the safety culture

•Everyone can do it naturally because it makes sense, and is a benefit to each individual as well as to the organization

EMS PRINCIPLES

But what is the different between ISO 14001 and 9001?

Boss to staff:“We’d like to develop your leadership skills so we are putting you in charge of the ISO 14001 project”

EMS PRINCIPLES

Quality Policy Organization

Management Representative

TrainingDocument and Data Control

Quality System Procedures, Contract Review, Design Control, Purchasing, Process Control, Handling, Storage,

Packaging, Preservation and Delivery, Servicing

Inspection and Testing, Control of Inspection, Measuring and Test

EquipmentCorrective and Preventive Action

Control of Quality RecordsInternal Quality Audits

Management Review

Environmental PolicyResources, Roles, Responsibility and Authority

Competence, Training and AwarenessDocument ControlOperational Control

Monitoring and Measurement

Non-Conformance and Corrective and Preventive Action

RecordsEnvironmental Management System

AuditsManagement Review

ISO 9001 ISO 14001

Similarities between ISO 9001 and ISO 14001:

EMS PRINCIPLESThe ISO 14001 EMS Model

4.5.1 Monitoring & Measurement4.5.2 Preventive & Corrective Action4.5.3 Records4.5.4 EMS Audit

4.5.1 Monitoring & Measurement4.5.2 Preventive & Corrective Action4.5.3 Records4.5.4 EMS Audit

4.4.1 Resources, Roles, responsibility and authority4.4.2 Competence, Training & Awareness4.4.3 Communication4.4.4 Documentation4.4.5 Document Control4.4.6 Operational Control4.4.7 Emergency Preparedness

4.2 Define Policy4.2 Define Policy

4.3.1 Identify Aspects4.3.1 Identify Aspects

4.3.2 Legal Requirements

4.3.2 Legal Requirements

4.3.3 Identify Objectives Targets and Programs

4.3.3 Identify Objectives Targets and Programs

4.4 Implementation and Operation

4.4 Implementation and Operation

4.5 Checking4.5 Checking

4.6 Management Review4.6 Management Review

3.2 Continual Improvement3.18 Prevention of Pollution

Products, Services, and

Activities

4.1 General Requirements

4.2 Environmental Policy

4.3 Planning Environmental aspects Legal and other requirements Objectives, Targets and Programs

4.4. Implementation and Operation Resources, Roles, Responsibilities and Authority Competence, Training and Awareness Communication Documentation Controls of documents Operational control Emergency Preparedness and Response

4.5 Checking Monitoring and Measurement Evaluation of compliance Nonconformity, Corrective action and Preventive action Control of records Internal audit

4.6. Management Review

EMS PRINCIPLES – THE STANDARDS REQUIREMENTS

GENERAL REQUIREMENTS Establish, document, implement, maintain and continually improve (EDIMC) EMS

In accordance with ISO 14001:2004 Determine how the EDIMC fulfill ISO

14001:2004 requirements Define and document the scope of

EMS

EMS PRINCIPLES

OUR SCOPES?

“Teaching and Learning”

EMS PRINCIPLES

ENVIRONMENTAL POLICY The environmental

policy describes the organization’s overall approach and intentions.

Is the Keystone upon which the entire EMS is constructed.

NOT A PUBLIC RELATIONS DOCUMENT

Policy

Management Review

Implementation and OperationChecking

Planning

EMS PRINCIPLES

POLICY REQUIREMENTSTo meet ISO 14001 requirements, the policy must:

Be appropriate to the nature, scale, and environmental

impacts of the organization activities and goods produced.

Include a commitment to continual improvement and

prevention of pollution.

Include a commitment to comply with applicable legal

requirements and other requirements to which organization

subscribes.

Provides the framework for setting and reviewing

environmental objectives and targets.

Be documented, implemented and maintained, and

communicated to all employees (also persons working on

behalf)

Be available to the public.

EMS PRINCIPLES

PLANNING Environmental

Aspects.

Legal and Other Requirements.

Objectives, Targets and Program(s).

Policy

Management Review


Planning

EMS PRINCIPLES

S.M.A.R.T.

PLANNING

Teaching&

LearningActivities,Products

&Services

IdentifyEnvironmental

Aspects

DetermineSignificant

EnvironmentalAspects

Determine Legal and Other

Requirements

Establish

Objectives

and

Targets

Develop

Environmental

Management

Programs

EMS PRINCIPLES

ACTIVITIES, PRODUCTS AND SERVICES What to consider within described &

defined scope of the EMS?

Consider mission – what ‘facility’ is designed to do e.g. lecture halls, labs, and… etc.?

Consider activities that support the mission e.g. lectures, lab experiments and… etc.?

Consider actions that are both regulated (controlled) and not regulated (not controlled) e.g. commuting to work/lectures

EMS PRINCIPLES

ASPECTS AND IMPACTS Identify environmental aspects of activities products

and services within defined scope of EMS that can be

controlled and over which can be influenced taking into

account planned or new developments, or new or

modified activities, products and services” Aspects: Element of an organization's activities,

products or services that can interact with the environment.

Impacts: Any change to the environment, whether adverse or beneficial, wholly or partially resulting from an organization's activities, products or services

EMS PRINCIPLES

ASPECTS AND IMPACTS

Activitys vs Aspects vs Impacts

EMS PRINCIPLES

ASPECTS AND IMPACTS Content Requirements of Environmental Aspects

understand how organization interacts with the environment

control versus influence arrive at a list of significant environmental

aspects based upon impactsdevelop a procedure to support this three step

decision making process

EMS PRINCIPLES

EMS PRINCIPLESEveryone & Everything Impacts The Environment

Either adversely or beneficially!

EMS PRINCIPLES

Environmental receptors: People (public)

Public nuisance Natural Resources

Consumption of non-renewable resources Land/Soil

Soil excavation, erosion, solid contamination Water

River water contamination, wastewater discharge Air

Emissions of heat, particulates, GHG, GST?!

DETERMINE SIGNIFICANT ASPECTS The process of arriving at a list of Significant

Environmental Aspects must be a reasonable and understandable procedure be based upon the following criteria:

1. perceived risk(human health vs. ecosystem);2. impact analysis (internal, local, regional, global);3. probability of occurrence4. direct or indirect control;5. regulated or non-regulated;6. resource utilization;7. community interest;8. etc.

Consider normal, unique, and emergency conditions

Where do opportunities exist for improvement?

EMS PRINCIPLES

LEGAL AND OTHER REQUIREMENTS Identify legal requirements that apply to a facility’s

activities – use audit guides or protocols

Identify other requirements that apply including corporate policies, Executive Orders (public organizations), facility initiatives or voluntary practices

ISO 14001 does not require documentation for the Legal and Other Requirements section (4.3.2). However, the only practical way to demonstrate conformance is to assemble in one place a list and copies of each applicable environmental law, regulation and voluntary subscription along with the supporting permits and/or contracts as evidence.

EMS PRINCIPLES

OBJECTIVES AND TARGETS

Consider “legal and other requirements”

Consider significant aspects

Reflect corporate policies

Reflect financial and technical limitations

Reflect “interested parties”

Reflect policy commitment and commitment

to pollution prevention

Consider how you will measure progress

EMS PRINCIPLES


Objectives are the “Goals” that support the “Vision” contained in the

Environmental Policy Statement.

EMS PRINCIPLES

ISO 14001 SPECIFICATIONS FOR OBJECTIVES/TARGETS

The ISO 14001 Standard stipulates several criteria that must be considered when establishing environmental objectives. Specifically:

Environmental policy commitments to continual improvement, prevention of pollution, and compliance with legal and other requirements.

Concentration on controlling significant environmental aspects – the activities, products, and services with the highest environmental impacts – since reducing their significance (i.e., the risks associated with them) automatically lowers their impacts.

Taking consideration of technological options and financial, operational, and business requirements means that environmental objectives and targets must be practical in terms of being technologically achievable, within the limits of available budget constraints, and consistent with operational and business strategies. In other words, objectives and targets must be realistic and attainable,

not mere dreams or wish lists. The views of interested parties. Any individual, group, agency, or community

that may be affected by or have a stake in the operations of the facility implementing the EMS. This can be a long list, including: National, regional/provincial, local government officials Local community representatives Public interest groups and other stakeholders (The views of interested

parties are also helpful when an organization makes a decision regarding communication of its environmental aspects).

EMS PRINCIPLES

ISO 14001 ENVIRONMENTAL MANAGEMENT PROGRAMS:

The organization shall establish and maintain programs for achieving its objectives and targets, including:

(a) designation of responsibility for achieving objectives and targets at each level and function of the organization

(b) the means and time-frame by which they are to be achieved

EMS PRINCIPLES

ENVIRONMENTAL MANAGEMENT PROGRAMS

An EMP is an action plan specifying:How objectives and targets will be accomplishedWho is responsible for achieving themWho will manage and supervise the activitiesWho will carry out the workWhat they will doWhat resources are needed (e.g., people, skills, equipment, time, money)When the tasks will be completed (i.e., a schedule)

EMS PRINCIPLES

ISO 14001 PLANNING SEQUENCE

ENVIRONMENTAL POLICY

Guiding Light

ENVIRONMENTAL ASPECTS

Problem Definition

LEGAL AND OTHER

REQUIREMENTS

Obligations


Goal Setting

ENVIRONMENTAL MANAGEMENT

PROGRAMS

Means of Achieving

Goals

EMS PRINCIPLES

IMPLEMENTATION AND OPERATION This phase includes 7 elements: Resources, Roles,

Responsibilities and Authority

Competence, Training and Awareness

Communication Documentation Controls of documents Operational control Emergency Preparedness

and Response

Policy

Management Review

Implementation and Operation

Checking and Corrective Action

Planning

EMS PRINCIPLES

IMPLEMENTATION AND OPERATION

Resources, Roles,

Responsibility &Authority

Competence,Training &Awareness

Document Control

EMS Documentation

Emergency preparedness and response

Communication

Operational Control

Organization &Accountability

Capabilities &Communications

Controls

EMS PRINCIPLES

RESOURCES, ROLES, RESPONSIBILITY & AUTHORITY

Roles and responsibilities are defined,

documented, communicated

Management will provide resources for

implementation of the system

Identifies Management Representative (s) In charge

Report to top management

EMS PRINCIPLES

COMPETENCE, TRAINING AND AWARENESS

Ensure competence training to regulatory requirements

standard operating procedures

Ensure training and awareness relevant to EMS - including policy

relationship between employees’ activities and

environmental impacts

EMS PRINCIPLES

COMMUNICATION

Ensure internal communication

External communication of significant environmental impacts is optional, however this decision shall be documented

Provide process for responding to external communication

EMS PRINCIPLES

DOCUMENTATION AND DOCUMENT CONTROL

Procedures for controlling documents

can be located - are legible, dated and

maintained

reviewed and revised as necessary and

approved

current versions are available to

practitioner

obsolete documents are removed from use

EMS PRINCIPLES

DOCUMENTATION Under ISO 14001, documentation refers to all

written material concerning the EMS

Documents include policies, procedures, manuals, plans, diagrams, flowcharts, correspondence, memoranda related to the EMS

Records are documents, but under ISO 14001 are distinguished from documentation:

Documentation concerns what should happen Records contain information on what has happened

EMS PRINCIPLES

SHALL DOCUMENT4.2 ENVIRONMENTAL POLICY

4.3.1 Environmental aspects

4.3.3 Environmental objectives and targets

4.4.1 Roles, responsibilities, and authority

4.4.3 Communications from external interested parties

4.4.4 EMS core elements

4.4.6 Procedures essential for operational control

4.5.1 Monitoring and measurement of key operations that have potential significant impacts

4.5.2 Compliance with laws and regulations

4.5.3 Records

4.6 MANAGEMENT REVIEW

EMS PRINCIPLES

MUST DOCUMENT4.3.2 Significant environmental aspects

4.3.3 Registry of legislation and regulations

4.3.4 Environmental management programs - action plans to achieve objectives and targets

4.4.2 Training needs results, and training plans

4.4.7 Emergency response plan

4.5.2 Corrective and preventive actions

4.5.5 EMS audit results

EMS PRINCIPLES

WHAT ARE OPERATIONAL CONTROLS?

Means by which an organization prevents pollution from operations, e.g.:

Pollution control equipment such as scrubbers, filters, precipitators, clarifiers, biological and chemical treatment, etc.

Alarms for gas, pH, conductance, tank level, etc. Preventive maintenance practices Operating procedures

EMS PRINCIPLES

METHODS OF OPERATIONAL CONTROL

Process controls: Electronic Mechanical Monitoring observation

Operating procedures: Verbal documented

EMS PRINCIPLES

WHAT IS A PROCEDURE?

An activity carried out according to specified instructions

Combination of responsibilities, authority, resources, instructions needed to consistently perform an activity

A procedure may be documented (i.e., written), but a document is NOT necessarily a procedure

EMS PRINCIPLES

ONE MORE THING FROM ISO 14001 4.4.6

The organization shall establish and maintain procedures related to the

identifiable significant environmental aspects of goods and services used by the

organization and communicate relevant procedures and requirements to suppliers

and contractors

EMS PRINCIPLES

RESPONSIBILITIES OF CONTRACTORS AND SUPPLIERS

The organization is responsible for informing contractors and suppliers about operating procedures relating to their goods and services

Contractors must comply with all EMS requirements when on site

Suppliers may be required to meet specified environmental standards in their own facilities

EMS PRINCIPLES

EMERGENCY PREPAREDNESS AND RESPONSE

Procedures to address accidents and emergencies prevent and mitigate environmental impacts

review and revise after emergency or accident

test where appropriate

EMS PRINCIPLES

CHECKING 5 elements:

Monitoring and Measurement.

Evaluation of Compliance

Nonconformity, Corrective Action and Preventive Action.

Control of Records

Internal Audit.

Policy

Management Review


Planning

EMS PRINCIPLES

CHECKING

RecordsOngoingMonitoring and

Measuring

Periodic Internal EMS Audits

Nonconformity,Corrective action and

Preventive Action

Periodic Evaluations of compliance

EMS PRINCIPLES

MONITORING AND MEASURING Procedures to monitor and measure activities

related to significant aspects

Root cause analysis

Audits

Track performance, operational control and objectives and targets

Maintain and calibrate monitoring equipment

EMS PRINCIPLES

EVALUATION OF COMPLIANCE

Periodically evaluate compliance with applicable legal requirements

Also evaluate compliance with other requirements the company subscribes

Keep records of such evaluations

EMS PRINCIPLES

NONCONFORMITY, CORRECTIVE ACTION AND PREVENTIVE ACTION

Identify cause of nonconformity

Develop corrective action and implement it

Modify procedures if necessary to prevent

recurrence

Define responsibility and authority to address non-

conformance

EMS PRINCIPLES

CONTROL OF RECORDS

Procedures for identification, maintenance and disposition of environmental records

Legible and traceable to the activity,

product or service involved

EMS PRINCIPLES

INTERNAL AUDITS Periodically audit to determine if the EMS

is being properly implemented and maintained, and

conforms to the standard

Provide audit information to management

EMS PRINCIPLES

MANAGEMENT REVIEWReview inputs:

Opportunities for improvementNeed for changes to EMS

Environmental policy Environmental Objectives

and Targets.Based on inputs (a - h)

Review outputs:Decision and actionConsistent to continual improvement

Policy

Management Review

Implementation and Operation

Checking and Corrective Action

Planning

EMS PRINCIPLES

MANAGEMENT REVIEW PROCESS

Need to consider:

• audit findings• progress records on objectives• changes to facilities• changes in activities, products or services• changes in technology• concerns of interested parties• other relevant information

To Assess the

• suitability,• adequacy, and• effectiveness of the EMS

In order to determine the need for change and improvement to:

• the environmental policy

• the objectives and targets

• other elements of the EMS

EMS PRINCIPLES

EMS INTERNA

L AUDITIN

G

EMS INTERNAL AUDITING

What is EMS Internal Auditing?

•The assessment of processes to verify that they are operating within planned arrangements:

o are procedures followed?o are procedures effective for

their purpose?o do they meet the requirements

of ISO 14001?

•Factual statements of observations backed by evidence

•Evaluation of processes NOT people

•Not compliance audits

EMS INTERNAL AUDITINGWhy EMS Internal Auditing?

•As a checking mechanism of the EMS plan and implementation

•Verify existence and implementation of EMS procedures and other arrangements

•Is EMS achieving its intended objectives?

•Preparation for certification/third party audits

•Provides information on the results of audits to management


Can do sampling for internal audits?


NO:The need to conduct the audit for all area/function/department implemented with the systems to ensure consistent implementations throughout the organizations

Can do sampling for internal audits?

YES:When assessing/evaluating sets of data with regards to records of an operations or monitoring over a certain period of time using acceptable uncertainty sampling methods


What The EMS Auditor Needs To Know?

•ISO 14001 Requirements•Auditing Techniques and Procedures•System Thinking and Analysis•The System Being Audited•Environmental Exposures and Prevention•Organizational, societal & governmental expectations


Why?

Audit has to be based on objective evidence. They have to be seen as a testimonial with the aim of evaluating at least the following aspects of Environmental Management Systems:•system performances •necessities that the system has to realize•strong points of the system•weak points of the system.


Things need to be established:

•Programs and procedures for periodic EMS audits ("snapshots")

•Extent and frequency based on results of previous audits

•Results given to management for EMS review

•Performed by independent (internal or external) auditors

•Based on satisfying pre-established objective criteria


Audit disclosures:

•EMS auditors are not looking for non compliances

•EMS auditors are generally not sufficiently versed to designate non-compliances

•The EMS audit reports deal with non conformances to the organization's own EMS


Collecting objective evidence:

•Collect sufficient evidence through interviews, examination of documents and observation of activities and conditions

•Information from interviews should be verified through observations, independent sources, records and existing measurements

•Audit findings should be reviewed with auditee to establish their factual basis


EMS Audit Indicators:

•Adequacy of documents, procedures, programs, records

•Implementation/integration/consistency

•Progress towards objectives and targets for:- compliance- operational controls- reductions- efficiencies- financial returns

•Commitment by management to:- environmental policy- EMS

•Awareness and competency of employees•Continual improvement of EMS


EMS Internal Audit Levels:

•Buy-in on the Concept of EMS

•Definition (creation) of the EMS

•Deployment and Use of the EMS:• Is it being used?• Are the elements current?• Are the elements effective?• Is EMS used strategically?


Tools needed:

•Standard reference guidance

•Internal audit procedures (Ref.: UPM/ISO-EMS/P004; Semakan 00; Isu 01; 15/7/2013)

•Audit checklists

•Audit notes


Presentation of findings - categories:

•Major non-conformity

•Minor non-conformity

•Observations/opportunity for improvements

•Verbal


Reporting of audit findings:

•Audit report

•Resolution of non-conformity• Determination of root cause• Immediate corrections• Corrective actions

•Records

Hafriazhar Mohd. Mokhtar

[email protected]

+6019 258 5819