Environmental Management System Management Audit Report
Environmental Management System Management AuditReportAugust 1-5, 2005PurposeThomas Jefferson National Accelerator Facility (JLab) intends to self-declareimplementation of an Environmental Management System (EMS) in the fall of 2005. Inpreparation for self-declaration this internal audit of the Lab's EMS was conducted inaccordance with JLab SOP EMP-14, Internal Audit. Non-conformances, e.g. failures tomeet a requirement, identified in the audit are to be addressed before self-declaration.ScopeThe audit encompassed all of the EMS requirements defined in ISO 14001:2004 andcovered activities on the Lab's main campus as well as in off-site rented/leased spacesuch as Blue Crab Storage. The audit sought to determine whether the EMS that JLab isnow implementing satisfies the requirements of ISO 14001 and whether the requirementsof the EMS (including staff awareness of the EMS) are being met in the field.PlanThe audit plan was created by the audit team as part of its training and approved by theEMS Management Representative. The audit assignments were set so that no one auditedwork in which he or his line management had participated, in order to maintainobjectivity.The audit was divided into two pieces: audit of the EMS as a whole for conformance tothe requirements of ISO 14001 and audit of awareness and implementation of the EMS inthe field.In order to audit the field the team prepared a matrix of Lab area versus significantenvironmental aspects and planned the audit to sample all areas and all significant aspectcategories. The matrix and the resulting audit assignments are shown in Annex 1.Audit TeamThe audit team was chosen by the EMS Management Representative from across JLaband also included two consultants from Gannett Flemming, Inc., the firm that has beenassisting in the Lab's development and implementation of an EMS. Team members andtheir organizations:Dave Buckle1Mary Erwin3 (EMS Management Representative)Chuck Mason2Jim Murphy3 (Lead Auditor)1CIOCFOGannett Flemming, IncOA8/16/05
Dena Polyhronakis2Steve RowleyTim Rothgeb1Administrative DivisionGannett Flemming, Inc.Accelerator DivisionGannett Flemming, Inc. trained the internal members of the team before the audit. Mostof the audit was performed by two-person subteams. These three teams are indicated bysuperscripts following the names. Steve Rowley, who had not participated in the JLabEMS project before the audit, was charged with auditing the conformance of the overallEMS to the ISO 14001 standard.ResultsFindings were graded as follows: OK - Item meets ISO 14001 and/or other requirements including the JLab EH&SManual and SOPs. Noted on Corrective Action Request forms (CARs) only inparticularly significant cases. Observations - Items which meet the intent of the requirements, but with minorinconsistencies. Noted on CARs, but no response required. Not tracked. Minor - Not an EMS failure, but a failure in some part of the documentation or asingle observed failure in conforming to one requirement. Tracked. Major - EMS failure. The absence or total breakdown of an EMS requirement, ora number of minor findings against a single requirement. Tracked .The audit recorded 25 observations, six (6) minor and two (2) major non-conformances.The major non-conformances: Several people interviewed were not aware of the environmental policy or theEMS in general. Those who were aware knew about it mostly through informalchannels. Root cause: employee not trained.Recommended Corrective Action: Perform JLab wide awareness trainingincluding training on the environmental policy. JLab has not performed a compliance audit per EMP-11.Recommended Corrective Action: Perform a compliance audit of JLab per EMP11 and maintain records of the audit.The minor non-conformances: TIPs should be updated with the status of the specific actions. Also the targets areexpressed as tasks rather than a quantifiable performance level as required.Recommended Corrective Action: Update TIPs to show status. Express targetsas the quantifiable performance level and deadline to help meet the broaderobjective. Operational controls have not been developed for all significant environmentalaspects.28/16/05
Annex 1: Audit PlanSignificant Environmental Aspect CategoriesAreaACCServiceBuildingsACC TunnelARC LabBlue st LabSecurity InvolvementMedical/VARCAdmin/VARCManagement SystemElementsTeam IonizingRadRadiation RegulatedWasteXXXXXXXXXXX1, 2&3CM2X2XXXXXXXXXXXXXSRTeam 1 Dave Buckle and Tim RothgebTeam 2 Dena Polyhronakis and Chuck MasonTeam 3 Mary Erwin and Jim MurphyCM Chuck MasonSR Steve RowleyAnnex 2: Corrective Action RequestsAll CARs will be attached.48/15/05
EMS to the ISO 14001 standard. Results Findings were graded as follows: OK - Item meets ISO 14001 and/or other requirements including the JLab EH&S Manual and SOPs. Noted on Corrective Action Request forms (CARs) only in particularly significant cases. Observations - Items which meet the intent of the requirements, but with minor inconsistencies. Noted on CARs, but no response required .
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4.1 Quality management system audit 9.2.2.2 Quality management system audit - except: organization shall audit to verify compliance with MAQMSR, 2nd Ed. 4.2 Manufacturing process audit 9.2.2.3 Manufacturing process audit 4.3 Product audit 9.2.2.4 Product audit 4.4 Internal audit plans 9.2.2.1 Internal audit programme
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