United States
Environmental Protection
Agency
Office of Enforcement &
Compliance Assurance
Washington, DC 20460
December 1996
EPA 300-B-96-012B
3rd Edition
&EPA
GENERIC PROTOCOL FOR
CONDUCTING ENVIRONMENTAL
AUDITS OF FEDERAL FACILITIES
Phase 3: Auditing Environmental Management Systems
-PRO"
Prepared
by the Members
of the Interagency
Environmental Audit
Protocol Workgroup
for the Federal
Community
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Phase 3
Conducting Environmental Management
Assessments of Federal Agencies
Table of Contents
Introduction
A. Purpose 1
B. Scope and Format 1
C. Approach 3
Protocol Disciplines for Facility Wide Environmental Management Systems
Section 33 Organizational Structure 4
Section 34 Environmental Commitment 13
Section 35 Environmental Protection Programs 21
Section 36 Formality of Environmental Program 28
Section 37 Internal and External Communication 37
Section 38 Staff Resources, Training, and Development 44
Section 39 Program Evaluation, Reporting and Corrective Action 53
Section 40 Environmental Planning and Risk Management 60
Appendix - Selecting Documents to Review and Individuals to Interview for
Environmental Management Assessments 67
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Introduction
A. Purpose
The primary purpose of conducting an environmental management systems
assessment from an agency wide or macro level is to provide the facility management or
agency headquarters staff with concise information pertaining to:
•• Strengths and weaknesses of environmental management systems and programs at
either a specific facility or throughout the agency;
•• Adherence with Best Management Practices pertaining to environmental
management systems and programs;
•• Compliance with the agency's policies which address environmental management
systems and programs;
•• Identification of underlying causal factors contributing to the occurrence of observed
compliance deficiencies; and
•• Noteworthy environmental management practices.
These assessments are also intended to provide facility management or headquarters
staff with feedback on the effectiveness and benchmark performance of their
environmental management systems and to identify opportunities for improvement.
Phase 3 reviews the "big picture" by assessing the overall functioning of established
environmental management systems at a facility or throughout the entire agency. This
document divides Phase 3 protocols into the eight organizational disciplines listed below
and attempts to provide assistance to agency headquarters staff and facility management
when they seek to understand and evaluate the systems which have been developed to
manage and control environmental performance. In this review, the task of the assessor
shifts from compliance auditor (Phase 1) and systems specific environmental program
evaluator (Phase 2), to systems function evaluator of environmental performance at either
the overall facility or at all facilities through the agency.
B. Scope and Format
The scope of an environmental management systems assessment includes eight
disciplines which are based on key characteristics and elements of effective environmental
management systems. These eight disciplines are the following:
•• Organizational Structure;
•• Environmental Commitment;
•• Environmental Protection Programs;
•• Formality of Environmental Programs;
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•• Internal and External Communication;
•• Staff Resources, Training, and Development;
•• Program Evaluation, Reporting, and Corrective Action; and
•• Environmental Planning and Risk Management.
(NOTE: Pollution prevention is dealt with comprehensively in each of the sections of
Phase 2 as it pertains to those disciplines. Additionally, a pollution prevention
assessment guide has been provided as an Appendix to Phase 2.)
Each discipline is organized as follows:
•• Performance Objective: This is a general statement of the overall objective to be met
in each discipline.
•• Key Evaluative Concerns: This section provides information on the major elements
that will be evaluated in each discipline.
•• Criteria: These are specific criteria that should be satisfied in order to meet the
overall performance objective for each discipline. Each criteria is identified by a
capital letter. The criteria within a discipline have been grouped and organized along
the lines of the major elements identified in Key Evaluative Concerns.
The bullets under each criterion are intended to provide guidance to the assessor in
evaluating that criterion; they are not intended to be subcriteria. Additional bullets or lines
of inquiry may be appropriate depending on the specific organization being reviewed.
Many Federal facilities have tenant organizations, usually other Federal agencies, but
also state and local agencies and private parties. Even though these tenant organizations
may be responsible for environmental compliance of their activity, the facility owner may
be ultimately held accountable by regulators should compliance problems persist or should
future liabilities be discovered. These protocols can be used to address environmental
compliance and management issues associated with tenant organizations. The agreements
between the facility owner and the tenant organization need to clearly establish
environmental responsibilities of both the facility owner and tenant organization and the
mechanisms that the facility owner will utilize to monitor compliance, including application
of these protocols to the tenant organizations.
Federal facilities must observe the requirements of Executive Order (E.O.) 12088 to
ensure that sufficient funding for compliance with applicable federal, state, and local
environmental requirements are requested in the agency budget. The FEDPLAN planning
process is a systematic methodology for identifying and prioritizing environmental
requirements, and targeting resources necessary to address them. The process assists in
establishing funding priorities for projects to meet statutory and regulatory requirements.
Using a standardized format, Federal agencies must update their plans annually and
submit them to the Office of Management and Budget (OMB) through EPA for review.
EPA uses a computerized system (FEDPLAN-PC) to track these requirements from the
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time they are first identified until they are executed. The procedures for developing
Federal agency environmental plans are discussed in detail in the EPA document "Federal
Agency Environmental Management Program Planning Guidance," dated October 1994.
C. Approach
In an assessment of facility wide environmental programs, the responsibility of the
environmental management specialist is to assess these programs to determine whether
they effectively meet the performance objectives and whether they have sufficient structure
and formality to assure that activities are conducted in a manner that is consistent with
environmental regulations and Federal agency policy.
The assessment is based on a combination of staff interviews and document reviews.
Interviews are exceptionally important in conducting an Environmental Program
Assessment. They provide the primary means of understanding the organizational
relationships, roles and responsibilities, policies, and systems that form the framework for
the management of environmental matters. More importantly, they often reveal differences
in the actual versus the documented practices. Document review is important to verify the
formality of the system and confirm interview information. Suggestions for the type of staff
to interview and documents to review are provided in the appendix.
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Phase 3
Section 33
Assessing Environmental Programs
Organizational Structure
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Phase 3
Section 33
Table of Contents
1. Performance Objective 8
2. Key Evaluative Concerns 8
3. Criteria 8
A. Management Organization 8
B. Roles and Responsibilities 10
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1. Performance Objective
The structure of the organization being assessed should be such that environmental
management functions are congruent and effectively integrated with other functions and
processes. Roles, responsibilities, and accountabilities should be well defined and clearly
communicated to effectively manage environmental issues. Authorities should be delegated
to organizational levels that can ensure the effective implementation of environmental
programs.
2. Key Evaluative Concerns
In this assessment discipline, the organization of the environmental management
organization will be reviewed and evaluated. Important characteristics of an effective
organizational structure include well defined roles and responsibilities, sufficient
authorities, appropriate layers of management, effective reporting relationships, and
congruence of the environmental management organization with the larger Federal agency
organization.
3. Criteria
A. Management Organization
1) The organizational structure of the environmental management function
is characterized by clear lines of authority and responsibility.
a. Review organizational charts, mission statements, and any other
documentation of organizational design for the environmental
management function.
b. Determine whether departmental missions and responsibilities
related to environmental management are clearly defined and
understood. Note any overlaps or conflicts of interest.
c. Determine which offices and individual(s) have authority and
responsibility/accountability for various environmental management
functions.
2) The environmental management function is organized in such a way that
managers can be leveraged effectively, without being spread too thinly.
a. Determine the breadth and depth of responsibility of key
environmental managers.
b. Determine whether environmental managers have too much
responsibility to effectively carry out their jobs.
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c. Determine whether environmental managers have too little
responsibility to be cost effective to the organization.
3) Reporting relationships within the environmental management function
are well defined, clearly communicated, and effectively integrated into the
overall organizational structure.
a. Interview mangers and environmental staff to understand these
reporting relationships.
b. Determine where these relationships are defined and how they are
communicated.
c. Evaluate whether actual reporting arrangements for environmental
management (as determined through interviews) match those shown
on existing organizational charts or on distribution lists. Note any
differences.
d. Evaluate how well these reporting relationships and the
environmental management organization fits in with the overall
organization, e.g.,
Centralization versus decentralization; and
Line versus matrix organizational structure.
4) Environmental managers are positioned high enough in the organization
and have sufficient organizational stature, independence, and authority to
effectively implement environmental programs and to make decisions
related to environmental protection.
a. Understand the amount of authority given to environmental
managers at different levels and determine if it is sufficient to carry
out their responsibilities.
b. Understand the approval process and the level of approval necessary
for specific actions or projects.
c. Identify who has stop-work authority and how quickly they can
affect a necessary response.
d. Note how many reporting levels separate the organization's most
senior manager and the person in charge of environmental matters.
e. Determine whether there are too many layers of management
between these two positions (the organization's most senior
management and the environmental professional).
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f. Determine the effectiveness of communication between these two
positions (the organizations most senior management and the
environmental professional), (linkage with Section 37).
5) The integrity and effectiveness of the organizational structure is
periodically reviewed and revisions are made when warranted.
a. Note how often it is reviewed and by whom.
b. Understand the criteria used to evaluate organizational structure.
c. Determine whether the organizational structure of the
environmental management function has changed as a result of past
reviews.
B. Roles and Responsibilities
(linkage with Section 38)
1) Environmental roles and responsibilities are well defined, clearly
communicated, and understood by all personnel whose activities may
impact environmental performance.
a. Identify where and how these roles and responsibilities are defined,
such as in program manuals or job descriptions.
b. Verify through interviews that individual jobs and responsibilities
for environmental management match those in program plans and
job descriptions.
c. Determine whether specific roles as required by Federal agency
policy or Federal and state regulations have been assigned (e.g.,
NEPA Compliance Officer, Radiation Safety Officer).
d. Determine whether these roles and responsibilities are formally
implemented.
e. Determine whether functional relationships between the
environmental support group and the line units are formally defined
and understood.
f. Review tenant/host agreement(s) to ensure environmental
responsibilities are clearly defined between the tenant and the
agreement holder.
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2) Roles, responsibilities, and accountabilities are supported by management
systems and documentation such as job descriptions, performance standards,
and performance appraisals.
a. Review job descriptions and performance standards for a sample of
line management and operations staff to determine if appropriate
environmental responsibilities are included.
b. Review performance standards for select personnel (line managers
and operations staff) to verify that environmental performance is a
written criterion.
c. Determine, through interviews, whether performance appraisals
appropriately measure environmental performance for both
environmental staff and non-environmental staff.
3) Personnel responsible for environmental management are held
accountable for their performance and the performance of those they
manage.
a. Determine if awards are available for environmental activities or
actions.
4) A group independent of line management with responsibility for policy
and standards development and oversight and technical support has been
established. This group has the authority and management support to
implement their responsibilities.
a. Determine whether responsibilities of these support groups are
clearly defined.
b. Identify who:
Establishes organization-wide environmental policy and
standards;
Provides environmental oversight of line organizations; and
Provides technical support for line organizations.
c. Determine how these environmental support groups fit into the
overall organizational structure. Note the organizational placement
of environmental support groups and whether they are independent
of line management.
d. Determine whether these groups have appropriate levels of
authority.
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e. Determine if environmental managers have been successful in
implementing past initiatives.
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Phase 3
Section 34
Assessing Environmental Programs
Environmental Commitment
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Phase 3
Section 34
Table of Contents
1. Performance Objective 15
2. Key Evaluative Concerns 15
3. Criteria 15
A. Top Management Support 15
B. Environmental Policy 17
C. Line Management Support 18
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1. Performance Objective
The organization should exhibit a commitment to environmental excellence
demonstrated by top management support, line management accountability for
environmental performance, and formal environmental policy.
2. Key Evaluative Concerns
The focus of this audit discipline is the commitment to environmental excellence
exhibited throughout the organization — from top management through line management
and staff. Top management support is critical to ensure environmental excellence and is
necessary to emphasize the importance of and commitment to the organization's
environmental goals. Top management support is evaluated based on demonstration of
commitment to environmental programs and performance.
The existence of overall and issue-specific environmental policies is essential to
establish both a framework for and a direction to the organization's environmental
expectations. The organization's environmental policy will be evaluated in terms of
comprehensiveness, compliance with environmental requirements, and provisions for
environmental excellence that go beyond regulatory requirements.
Finally, to achieve environmental excellence, all personnel must take personal
responsibility for environmental performance. Line management's commitment is
evaluated based on the sense of responsibility for environmental protection shown by
managers and operating personnel at all levels and in all functions.
3. Criteria
A. Top Management Support
1) Top management clearly communicates its commitment to environmental
protection through the issuance of formal statements and policies that
explicitly state environmental goals and expectations, with full compliance
as a minimum goal.
a. Determine whether top management's commitment to
environmental protection has been stated in mission statements,
annual reports, general environmental policy, or other broadly
disseminated materials.
b. Determine whether top management includes environmental
protection in internal or external speeches.
2) Top management demonstrates its commitment to environmental
excellence through personal and managerial actions.
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a. Determine whether routine senior management meetings include
discussion of environmental issues/programs.
b. Determine if top management has supported environmental
programs through sufficient allocation of resources (financial,
technical) (linkage with Section 38 & Section 40).
c. Identify personal actions that provide evidence of top management
support, for example:
Initiation of environmental programs/projects;
Participation in professional associations;
Work with local community organizations; and
Participation in self-assessment reviews.
d. Determine whether senior management has a clear set of goals and
expectations regarding environmental performance and what they
are (e.g., environmental compliance as a minimum expectation,
goals that go beyond compliance, emissions reductions, etc.).
e. Compare explicit goals to apparent implicit goals and identify any
conflicting messages.
f. Identify how senior management communicates its environmental
goals and expectations to employees and, typically, how frequently
the goals are communicated.
3) Top management's commitment is demonstrated through required
routine reporting regarding environmental performance and the status of
environmental initiatives, (linkage with Section 37)
a. Determine what formal reports are routinely prepared for top
management and to what extent they address the organization's
environmental status or performance.
b. For these reports, identify to whom they are sent, the type of
information conveyed, and the level of detail provided.
c. If environmental information is not included in routine management
reports, investigate whether top management utilizes or relies upon
any informal means for determining the organization's
environmental status or performance. If yes, identify the means and
how it works.
d. Check for any formal written requests from top management for
information on environmental status or performance.
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4) Senior managers have a basic understanding of and appreciation for
environmental requirements relevant to the scope of the operations for
which they are responsible.
a. Through interviews, determine if senior managers understand
general regulatory requirements, and have knowledge of internal
environmental programs and responsibilities.
b. Determine what training or background these managers have
related to environmental management.
5) Top management encourages openness and is receptive to input on
environmental issues from all employees, as well as from the public at
large, (linkage with Section 37)
a. Identify mechanisms by which employee input has been encouraged
and identify examples.
b. Seek evidence that employee input is considered in environmental
decisionmaking.
c. Identify mechanisms by which public input has been encouraged and
identify examples.
d. Determine whether public input is considered in environmental
decisionmaking.
6) Top management has created a culture of compliance, awareness,
teamwork, and line responsibility for environmental management.
a. Based on input from other members of the Assessment Team,
determine if such a culture exists in the organization and how this
culture was established.
b. Determine top management's role in encouraging or discouraging
such a culture.
B. Environmental Policy
1) A formal environmental policy statement that has been issued from a high
enough level of authority within the organization to communicate its
importance.
a. Determine the existence of and review the organization's formal
written statement of environmental policy.
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b. Identify the individual and level within the organization from which
the policy statement was issued.
2) Environmental compliance is formally established as the minimum
acceptable standard.
a. Review the environmental policy statement and identify its principal
environmental goals and objectives.
b. Determine whether the policy statement satisfies the Federal
agency's goal of achieving environmental excellence.
c. Note whether implementation guidance or other supplemental,
subsidiary statements clarify how the organization intends to meet
its policy objectives.
3) The organization has established issue-specific policies for the major
environmental issues consistent with the scope of its operations.
a. Determine whether the organization has issued any additional, issue-
specific policies addressing more focused environmental concerns,
e.g., underground storage tanks, PCBs, groundwater protection,
hazardous waste, air emissions, NEPA, etc.
b. Assess whether issue-specific policies are consistent with the overall
environmental policy.
4) Environmental policies are widely distributed, easily accessible, and
understood throughout the organization.
a. Identify how environmental policies are communicated.
b. Based on interviews, determine the level of awareness and
understanding of environmental policies.
C. Line Management Support
1) Individuals throughout the organization recognize the environmental
aspects of their job responsibilities, and take personal responsibility for
and demonstrate a sense of "ownership" of environmental protection.
a. Determine line management's sense of personal responsibility for
environmental performance.
b. Determine whether line operating personnel and functional
personnel understand how their individual jobs affect the
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organization's environmental performance and whether they make
any specific connections between the two.
c. Note specific instances which reveal management or staff attitudes
or beliefs regarding the importance of their contribution to good
environmental performance.
d. Determine whether attitudes and behavior of management reinforce
the message that line operating personnel are primarily responsible
for ensuring good environmental performance.
e. Determine the organization's sense of the relative importance of the
roles of operating personnel and environmental staff in determining
environmental performance.
2) Managers at all levels have formally stated and demonstrated their
commitment to environmental excellence.
a. Identify and review managers' statements of this commitment, for
example:
Memoranda;
Records of formal meetings; or
Bulletin board postings.
b. Identify actions that provide evidence of environmental
commitment.
3) Managers at all levels and in all functions whose activities may impact
environmental performance take responsibility and interest in limiting the
environmental impacts of their operations.
a. Identify activities in which line managers are involved, for example:
They routinely observe field level compliance activities;
Participate in audits and self-assessments;
Write and review procedures; or
Serve on environmental advisory committees.
b. Determine what kind of environmental information line managers
solicit and receive and how they obtain this information.
c. Review internal memos relevant to environmental management
activities and manager meeting minutes to assess their level of
involvement.
d. Determine what actions have been taken by line management in
response to environmental accidents and occurrences.
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4) Management and staff cooperate fully and openly with internal and
external oversight groups, (linkage with Section 33 and Section 37)
a. Based on interviews with internal environmental staff and external
oversight organizations, determine whether the relationship between
the two is cooperative or adversarial.
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Phase 3
Section 35
Assessing Environmental Programs
Environmental Protection Programs
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Phase 3
Section 35
Table of Contents
1. Performance Objective 23
2. Key Evaluative Concerns 23
3. Criteria 23
A. Specific Environmental Protection Programs 23
B. Specific Program Plans 23
C. Other Programs Related to Environmental Protection 24
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1. Performance Objective
Programs should be in place to ensure compliance with applicable Federal, state, and
local environmental protection laws and regulations, and internal Federal agency policies
that are designed to protect the environment and public health and welfare.
2. Key Evaluative Concerns
The purpose of this assessment discipline is to evaluate the extent to which the
organization has developed and implemented specific environmental protection programs
and plans which, if properly managed, should help maintain compliance and ensure
movement towards environmental excellence. This category will be evaluated based on the
existence, quality, and effectiveness of specific programs, including all necessary program
elements.
Whereas the other protocol areas evaluate specific characteristics and elements of
environmental management systems, this discipline will evaluate the implementation of
these systems for issue specific environmental programs.
3. Criteria
A. Specific Environmental Protection Programs (EPPs)
1) For each of the following programs identified in A-l below determine
whether a program is necessary and whether existing programs are
sufficient to identify, quantify, and control risks.
a. Determine whether applicable environmental programs include the
following program elements:
Formal policies and plans;
Identification and characterization of sources;
Understanding of applicable regulatory requirements;
Responsibilities;
Implementation procedures;
Recordkeeping and reporting systems;
Training; and
Program evaluation and oversight.
b. Evaluate the effectiveness of the organization's environmental
programs.
2) Effective environmental protection programs are in place to identify,
control, and monitor air emissions.
3) The organization has a program for the protection of surface waters
including:
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a. Identification of discharge points and sources;
b. Applicable discharge permits, monitoring program, an effective Spill
Prevention, Control, and Countermeasures Plan; and
c. Reporting and recordkeeping systems.
4) The organization has a program for the protection of potable water
supplies (including backflow prevention systems).
5) The organization has determined and documented the need for site
specific groundwater protection programs. When necessary, a
groundwater monitoring program has been established to address the
needs of specific sites.
6) Programs are in place for the proper management and control of toxic
and chemical materials to prevent or minimize their release into the
environment, including programs for:
a. Procurement, handling, and storage of toxic and chemical materials;
b. Management and control of polychlorinated biphenyls;
c. Management and control of pesticides;
d. Management and control of petroleum, petroleum products, and
chemicals in aboveground or underground storage tanks; and
e. Containment or removal of asbestos.
7) The organization has a program for the management of solid, hazardous,
and radioactive waste, including:
a. Waste source identification;
b. Waste characterization;
c. Waste acceptance criteria, where appropriate;
d. Treatment, storage, and disposal practices;
e. Contingency plans;
f. Recordkeeping systems;
g. Training;
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h. Waste minimization; and
i. A formalized pollution prevention program as outlined in relevant
executive orders.
8) Programs are in effect that provide for environmental radiation
protection through adherence to ALARA principals. Additional programs
are in place that require:
a. Radiological environmental surveillance;
b. Evaluation of unplanned releases of radioactive materials; and
c. Evaluation of radiation exposure to the public.
9) The organization has a program to identify, remove, and/or routinely
monitor underground storage tanks.
10) The organization has a program for compliance with Federal agency
requirements for implementing NEPA, including screening/review and
determination of the appropriate level of NEPA documentation for each
proposed action.
a. Identify the system to assess the acceptability of contractors
preparing NEPA documentation.
b. Determine whether environmental evaluations or checklists are used
to initially screen every proposed action.
c. Identify the criteria and process used to recommend the level of
NEPA documentation to the appropriate Federal agency authority
for determination.
B. Specific Program Plans
1) The responsible field organization has prepared and routinely updated
formal program plans for the following:
a. Groundwater protection management;
b. Waste minimization; and
c. Pollution prevention awareness.
2) The organization has developed an environmental monitoring and
surveillance plan.
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a. Determine whether the organization has a monitoring plan and
whether it addresses all environmental monitoring needs and
requirements relevant to the organization.
C. Other Programs Related to Environmental Protection
1). A program is in place to plan and effectively implement all actions
required to manage responses to releases of hazardous substances to the
environment from inactive waste sites or to releases of reportable
quantities of hazardous materials.
a. Determine whether the organization has formal written emergency
response plans, such as a Contingency Plan, Spill Prevention,
Control, and Countermeasures (SPCC) Plan, etc. as required.
b. Assess whether these plans are clear, complete, and current as to
who has the Emergency Coordinator responsibility, what emergency
response equipment is available and where, and whether the
emergency response procedures are site-specific.
c. Determine whether staff have received appropriate training in
planned emergency response procedures. Does the organization hold
periodic drills or other readiness exercises.
d. Review emergency response plan documents, internal records of
emergency response drills, other readiness exercises conducted.
2) The organization has developed and implemented preventive maintenance
programs to ensure proper operation of pollution control equipment.
(linkage with Section 40)
a. Determine what has been the operating experience of this
organization over the past year with respect to pollution control
equipment outage and needed repairs.
b. Assess whether the organization has preventive maintenance
programs in place and functioning for any critical operating and
pollution control equipment.
c. Determine whether preventive maintenance schedules are automated
or how responsible personnel know when a particular planned
maintenance activity is to be performed.
3) The organization has emergency preparedness plans such as contingency
plans, Spill Prevention, Control, and Countermeasures plans, and a
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general emergency plan that addresses any potential hazard including
natural disasters, fire, explosions, etc.
a. Verify that emergency response plans and programs include all
applicable elements, including roles and responsibilities, procedures,
training, and equipment.
b. Determine whether crisis management responsibilities are defined at
all organizational levels.
c. Review responsibilities in the emergency response plan against
organizational charts and general responsibilities.
4) A Quality Assurance Program and organization is in place to assure that
environmental programs provide adequate protection to the environment
and to public health, and that environmental data are representative and
defensible.
a. Determine whether environmental measurement activities are
conducted following EPA-approved methods and procedures.
5) A P2 plan outlines a facility's environmental future with respect to all
environmental impacts and compliance programs.
A. Pollution Prevention Plan Development Steps
Develop P2 goals;
Obtain Management commitment;
Establish a P2 team;
Develop a baseline;
Identify P2 activities and opportunities;
Develop criteria and rank the activities and opportunities; and
Conduct management reviews.
B. P2 Plan - a P2 program is a road map describing:
P2 activities;
The status of activities in progress;
P2 goals; and
Reductions achieved through P2 activities.
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Phase 3
Section 36
Assessing Environmental Programs
Formality of Environmental Program
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Phase 3
Section 36
Table of Contents
1. Performance Objective 30
2. Key Evaluative Concerns 30
3. Criteria 30
A. Regulatory Tracking and Translation 30
B. Procedures 31
C. Routine Facility Inspections 33
D. Recordkeeping and Reporting 34
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1. Performance Objective
Formal systems and procedures should be in place to manage day-to-day
environmental compliance. This includes systems to track and understand regulatory
requirements and procedures for implementation of policies and programs, routine
inspections, and systems for recordkeeping and reporting.
2. Key Evaluative Concerns
In this audit discipline, the formality of environmental programs and supporting
management systems for ensuring compliance will be evaluated. This discipline
complements the Environmental Protection Programs discipline by focusing on the formal
systems and controls that are in place to assure compliance of day-to-day operations. The
assessment team will evaluate the existence and effectiveness of a formal system for
tracking, interpreting, and distributing relevant regulatory requirements. The
organization will also be evaluated on its implementation of environmental programs
through specific guidance procedures and standards. The organization's system for the
conduct of routine inspections to identify and prevent problems will be evaluated. Finally,
systems for the maintenance and retention of records as well as assurance of necessary
reporting will be assessed.
3. Criteria
A. Regulatory Tracking and Translation
1) A formal system is in place to routinely track and interpret new and/or
changes to Federal, state, and local regulations and Federal agency
policies for the organization as follows:
a. Determine how the organization stays current with new and
emerging environmental regulations and trends;
b. Identify who within the organization is responsible for regulatory
tracking;
c. Determine how new regulations are interpreted as to their
applicability to the organization and by whom. Determine the role
of the legal department in this task;
d. Determine whether the organization has a formal system for
ensuring that new requirements are incorporated into existing
programs, policies, and procedures; and
e. Note the availability of regulatory reference material (compilations
such as BNA, automated access via software, etc.), technical books,
and other reference materials.
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2) A process exists to ensure that guidance on new regulatory requirements
is incorporated into organization or site-specific standard operating
procedures, as appropriate:
a. Determine if there is a formal system in place to update
environmental programs and procedures to reflect changes in
regulatory requirements.
3) Relevant regulatory information is routinely distributed to field
organizations in a timely manner:
a. Determine how and in what form regulatory information is
transmitted to the field; and
b. Determine whether the appropriate people learn of the developments
with sufficient lead time to take appropriate action.
4) Field organizations are provided sufficient guidance for compliance with
new regulations or policies in the form of guidance documents, sample
plans, and procedures:
a. Determine how this guidance is provided and by whom, such as
through guidance manuals, training, memorandum, etc.;
b. Determine the level of guidance provided to the field along with
regulatory distribution and assess the adequacy of this guidance;
and
c. Interview field personnel and obtain their opinion of the adequacy of
guidance.
B. Procedures
1) The organization has a formal, controlled process for reviewing, creating,
updating, and approving new procedures:
a. Develop an understanding of this process, including types of
approval, responsibilities, etc.; and
b. Test the system by identifying a sample of procedures to determine if
they have been reviewed and updated, by identifying a new
regulatory requirement, and by determining whether a procedure
has been created and approved.
2) Procedures and standards are issued from an organizational level with the
authority to mandate implementation (linkage with Section 33):
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a. Identify who issues environmental standards and their level of
authority within the organization; and
b. Assess whether the level of procedure issuance is sufficient to ensure
implementation.
3) Formal standards and procedures have been developed for the
implementation of specific environmental protection programs:
a. Determine whether the organization has written procedures for
environmental activities associated with specific environmental
programs, for example, inspections, reporting, emergency response,
and NEPA;
b. Review a sample of program specific procedures to assess the quality
and adequacy of instruction; and
c. Evaluate the process to review the technical content and adequacy of
NEPA documentation.
4) There are procedures to ensure that any activities that might impact the
environment are reviewed for environmental protection considerations:
a. Determine whether standard operating procedures include
environmental protection standards; and
b. Determine whether the organization has a system to ensure that all
procedures are reviewed and revised to include environmental
protection considerations (linkage with Section 40).
5) Procedures are part of a formal, auditable document control system
designed to ensure that personnel have ready access to current versions of
procedures containing environmental requirements:
a. Develop an understanding of how procedures are organized and
controlled, for example, whether procedures are centrally located or
at each individual operating site, and whether they are controlled
using a manual or computerized system;
b. Determine which environmental procedures are routinely accessible
at the facility level; and
c. Verify accessibility by requesting a sample of specific procedures.
6) The organization has implemented a system to periodically review and
update environmental procedures:
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a. Determine how often and by whom procedures are reviewed and
updated;
b. Determine how revised or updated procedures are
communicated/distributed to the rest of the organization; and
c. Determine whether there is a requirement for periodic review of
procedures by users.
C. Routine Facility Inspections
(linkage with Section 35 and Section 39)
1) The organization has a program for routine site and equipment
inspections and compliance checks, including appropriate documentation:
a. Determine whether environmental or other staff conduct occasional
or routine inspections to determine compliance with specific
environmental legal and regulatory requirements, and check the
frequency of these inspections;
b. Determine whether regular tests and inspections are performed on
critical operating and pollution control equipment (e.g., electrostatic
precipitators, scrubbers, air monitors, and environmental
measurement devices);
c. Determine whether these inspections follow a formal written
protocol or checklist; and
d. Determine whether results of inspections are documented and
retained. Review documentation of a sample of routine inspections.
2) The organization has a formal system for follow-up of exceptions noted in
inspections, which is supported by management review:
a. Develop an understanding of the follow-up system and
responsibilities;
b. Determine if there is a process for reporting exceptions to
management;
c. Determine whether management reviews inspection documentation
and corrective actions;
d. Determine if there is a tracking process to ensure that the corrective
actions or repairs are taken in a timely manner; and
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e. Determine whether the organization has a system in place to
minimize repeated exceptions as noted in inspections (e.g., through
root cause analysis).
D. Recordkeeping and Reporting
(linkage with Sections 33 and 35)
1) Systems are in place for the appropriate documentation and
recordkeeping of environmental performance:
a. Develop an understanding of all systems that are in place for
recordkeeping and document control:
Tracking of key regulatory schedules (e.g., permit renewals,
report submissions, required training.);
Maintaining compliance records (e.g., inspection logs, source
and/or ambient measurement data.); and
Preparing and submitting required regulatory reports (e.g.,
RCRA generator reports, hazardous material inventory and
release reports, PCB inventory and disposal reports).
b. Determine whether the organization maintains appropriate
documentation and records of environmental inventories, permits,
and environmental performance for the following programs:
Water pollution control;
Air pollution control;
Hazardous waste management;
Reportable spill incidents;
PCB inventory and disposal;
Toxic Substance Control Act Section 8(c) and 8(e) files;
Training; and
EPA.
c. In general, assess the state of the organization's files and
recordkeeping practices regarding these environmental records.
Determine whether the files are complete, current, and readily
accessible.
d. Determine the extent to which environmental information
management is automated or manual.
e. Determine whether recordkeeping practices are formal and
systematic.
2) The organization has a document control system and record retention
policy:
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a. Determine whether the organization has a formal records retention
policy which covers environmental compliance and other related
environmental information. In lieu of a formal policy, determine if
there are guidelines provided to staff regarding environmental
records retention;
b. Assess whether individuals are knowledgeable of the record
retention policy;
c. Where applicable, verify that the organization retains environmental
records for the retention period specified by regulation;
d. Determine whether the system has the capability to track the status
of NEPA compliance for planning, funding, approval, design, and
construction phases of all proposed actions; and
e. Determine whether the system accounts for classified
documentation, if necessary.
3) There are systems in place to ensure that environmental reports required
by Federal and state regulations and Federal agency policy are routinely
prepared and submitted on a timely basis:
a. Determine how the organization ensures that environmental reports
required by Federal or state regulations are routinely prepared and
submitted to the appropriate regulatory agencies in a timely
manner; and
b. Assess the effectiveness of the system by checking some reporting
requirements such as the following:
Annual hazardous waste generator reports have been
submitted to appropriate state or Federal EPA.
4) Environmental status reports with the appropriate level of detail are
routinely prepared for internal management purposes and for reporting
environmental concerns to higher levels of management in a timely
manner (linkage with Section 33 and Section 34):
a. Identify what kind of reports are prepared, and determine the
content and frequency of these reports;
b. Determine whether these reports include the full range of
environmental issues/activities;
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c. Determine whether other systems for conveying environmental
information are in place (e.g., regular meetings, reports, self
assessments, etc.);
d. Note whether environmental status information includes an
appropriate level of detail to sufficiently inform senior management;
and
e. Note whether environmental status reports compare
accomplishments to goals.
5) There are formal mechanisms to investigate, report, correct, track, and
monitor trends in environmental problems and "incidents," and types and
magnitudes of the problems that should be reported are well defined
(linkage with Section 39):
a. Determine whether the organization has a formal written procedure
for environmental incident investigation and reporting;
b. Review files of investigation reports to determine whether root
causes of problems and incidents are identified and trended and
whether there have been recurring problems; and
c. Determine whether corrective actions have been planned and
implemented for these incidents.
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Phase 3
Section 37
Assessing Environmental Programs
Internal and External Communication
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Phase 3
Section 37
Table of Contents
1. Performance Objective 39
2. Key Evaluative Concerns 39
3. Criteria 39
A. Internal Communication 39
B. External Communication 41
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1. Performance Objective
Formal and informal channels of communication should be used to facilitate
implementation of all environmental management systems and programs; to emphasize
management commitment to environmental protection; to generate a sense of
environmental awareness throughout the organization; and to manage relationships with
external oversight organizations and others who are likely to be concerned with the success
of the organization's environmental protection efforts.
2. Key Evaluative Concerns
The focus of this audit discipline is an evaluation of internal and external
communication systems. The effectiveness of internal communication systems will be
determined through an evaluation of the understanding of roles and responsibilities and
the awareness of environmental policies, procedures, and programs throughout the
organization. The extent and effectiveness of external communications will be assessed on
the basis of consistency of the external dialogue, monitoring of external concerns, and
external recognition of the organization's environmental commitment.
3. Criteria
A. Internal Communication
1) Environmental information is effectively communicated through formal
or informal means throughout the organization (top-down, bottom-up,
and lateral):
a. Determine whether these formal channels exist and in what form
(reports, meetings, memoranda, etc.);
b. Determine whether there are regular line management and
environmental staff meetings that adequately cover environmental
issues; and
c. Evaluate the flow of communication between line management and
operating staff, as well as between various functional areas.
2) There is a formal system in place to allow personnel to anonymously
communicate (without retribution) environmental concerns to upper
levels of management for resolution:
a. Determine whether such a system exists, how it works, to whom
concerns are reported, and what type of action is taken;
b. Determine whether personnel at various levels in the organization
are aware of its existence;
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c. Note any evidence that the system is used and whether it is
considered useful; and
d. Evaluate demonstrated management support for the system.
3) Informal channels of internal communication are encouraged as a means
of developing cooperation and commitment to environmental protection:
a. Identify the informal modes of communication used in the
organization and assess their effectiveness; and
b. Determine whether environmental staff across programs, facilities,
and units share information and assist each other on environmental
problems.
4) Environmental awareness is continually reinforced throughout the
organization via the use of newsletters, bulletin boards, videotapes, office-
wide programs, or other means (linkage with Section 37):
a. Identify communication modes used to promote environmental
awareness;
b. Note observations of environmental awareness promotion
throughout the facility; and
c. Compare environmental awareness with health and safety awareness
for perspective.
5) Formal communication of environmental protection directives is timely
and effectively reaches all responsible elements of the organization
(linkage with Sections 33 and 36):
a. Determine how quickly the following environmental information is
communicated to management:
Routine environmental status information;
Incident or major issue information; and
Controversial issues requiring NEPA.
b. Determine how quickly new environmental requirements, programs,
or other information is communicated to the field.
6) Employee environmental concerns are solicited and addressed, and both
concerns and responses are documented:
a. Identify employee environmental concerns that have and have not
been addressed;
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b. For those that were addressed, note the organization's response and
whether the concerns were documented;
c. For those that were not addressed, identify reasons why; and
d. Note whether well-founded concerns expressed in one facility or
group are shared with other facilities or groups that might have
similar problems.
7) The effectiveness of communication is demonstrated by a widespread
awareness and acceptance of the organizational commitment to
environmental protection (linkage with Section 34):
a. Through interviews, assess the general understanding of and
appreciation for environmental issues exhibited by organization
employees.
8) Effective working relationships exist between headquarters and field
environmental staff as well as between staff and line personnel whose
functional responsibilities impact environmental performance:
a. Check for close working relationships between environmental staff,
line management, and other key functional specialists within the
organization (e.g., engineering, legal, purchasing);
b. Note any examples where networking by environmental staff with
other professionals has resulted in decisions or actions that have
increased the effectiveness of the environmental management
function; and
c. Note any evidence of lack of cooperation between line and oversight
groups.
B. External Communication
1) The organization has a good working relationship and cooperates fully
and openly with external oversight organizations:
a. Determine whether the organization has frequent, proactive
interaction with regulatory agencies and keeps them informed of the
environmental status of the organization;
b. Determine whether the relationship between environmental staff and
external oversight organizations appears cooperative or adversarial,
based on interviews with representatives of both; and
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c. If appropriate, interview regulatory representatives to obtain their
perspective of the working relationship.
2) The organization has defined who will serve as the internal points of
contact with external parties and has identified the points of contact
within appropriate external parties:
a. Identify the key internal points of contact for interaction with
external organizations; and
b. Determine whether the organization has identified points of contact
in external organizations.
3) A program exists for communicating with external parties such as
regulatory agencies, environmental groups, and the local community to
provide them with the information and the opportunity to be involved in
key decisions related to environmental protection:
a. Determine what kinds of communication programs the organization
has with the local community (e.g., community relations plan,
education, visitation of facilities, public reading rooms, etc.);
b. Based on interviews with facility staff, assess how the organization
interacts with environmental groups;
c. Identify any complaints from neighbors, and determine how the
organization handles them;
d. Identify recent key decisions by the organization that have related to
environmental protection. Determine whether external agencies,
organizations, or individuals were provided the opportunity to be
involved; and
e. Based on interviews with regulatory agencies, environmental groups,
and representatives of the local community, determine whether
external organizations perceive that they have had such
opportunities.
4) Formal communication of environmental risks and protection efforts
occurs frequently, is timely, and effectively reaches external organizations,
including regulatory agencies, environmental groups, and representatives
of the local community:
a. Evaluate whether environmental risks and protection efforts are
communicated to such contacts routinely or only on an infrequent
basis, noting whether the information is timely; and
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b. Based on outside interviews, determine whether the information is
received and is perceived to be comprehensible. Determine whether
recipients believe they are being kept up to date on the
organization's activities that may impact environmental
performance.
5) The environmental concerns of external parties are addressed, and both
the concerns and responses are documented:
a. Review files to determine whether external concerns have been
documented and addressed; and
b. For those that were addressed, note the organization's response and
whether the concerns were documented and trended.
6) The effectiveness of communication is demonstrated by a widespread
external recognition of the organization's commitment to environmental
protection:
a. To the extent possible, determine the recognition of this commitment
among regulatory agencies, environmental groups, and
representatives of the local community.
7) The organization periodically assesses the effectiveness of external
communications, makes changes as necessary, and documents the results
of the evaluations and changes made:
a. Determine how the organization assesses effectiveness and what
changes have resulted from such an evaluation.
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Phase 3
Section 38
Assessing Environmental Programs
Staff Resources, Training, and Development
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Phase 3
Section 38
Table of Contents
1. Performance Objective 46
2. Key Evaluative Concerns 46
3. Criteria 46
A. Environmental Staffing 46
B. Job Descriptions and Performance Evaluations 47
C. Environmental Training Program 48
D. Staff Development Opportunities 51
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1. Performance Objective
Programs should be in place to ensure that staff resources are sufficient to effectively
develop and implement the organization's environmental protection programs. The
organization should have a formal program in place to ensure that all personnel have
received environmental protection training appropriate for their job responsibilities. The
organization also should provide staff development and career advancement opportunities
for environmental staff.
2. Key Evaluative Concerns
In this discipline, the assessment team will determine whether environmental staffing
resources are sufficient from a quantitative and qualitative perspective to properly address
the organization's environmental risks. Job responsibilities and performance appraisal
processes will be reviewed for evidence of the importance of individual environmental
performance. The degree of formality, completeness, and appropriateness of the
organization's systems for identifying and satisfying environmental skills training needs
and for providing opportunities for career development will also be assessed.
3. Criteria
A. Environmental Staffing
1) Environmental staffing levels are sufficient to achieve environmental
performance goals. This includes dedicated environmental support staff
and others with collateral duties (e.g., line managers with other support
functions):
a. Determine how the organization assesses environmental staffing
needs;
b. Determine whether staffing addresses identified needs;
c. Determine whether requests for additional environmental staff have
been approved or denied and why;
d. Identify environmental programs or projects that have not been
undertaken or completed because of insufficient environmental staff;
and
e. Note any other evidence of insufficient environmental staff to assure
compliance, for example:
compliance deficiencies whose root causes are inadequate
resources;
excessive overtime; and/or
excessive use of contractors.
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2) Personnel with environmental responsibilities have the relevant
background and training to carry out their responsibilities:
a. Determine what qualifications are necessary for environmental
staffing and other positions with environmental responsibilities;
b. Review a sample of resumes for selected environmental staff, and
note the following:
educational training in environmental management;
diplomas and certifications of environmental training (internal
and external); and
relevant work experience in environmental management.
c. Environmental support staff demonstrate sufficient knowledge and
familiarity with the organization's operations, environmental issues,
and programs and procedures to effectively carry out their
respective environmental protection responsibilities.
3) Staffing for environmental protection activities is provided in a timely
manner:
a. Determine whether additional staff with environmental
responsibilities are added as the need arises or whether there is a
significant delay; and
b. Determine whether environmental activities requiring immediate
attention (e.g., a spill or a determination of environmental
noncompliance) are responded to in a timely manner.
4) A system is in place to identify both short-term and long-term
environmental staffing requirements, both within the environmental
support group and within line units with environmental responsibilities:
a. Determine how short- and long-term environmental staffing
requirements are determined; and
b. Determine whether this staffing assessment includes both the
environmental support staff and line management needs.
B. Job Descriptions and Performance Evaluations
(linkage with Section 33 B)
1) Appropriate job descriptions are established and maintained for
environmental positions:
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a. Review formal written job descriptions for environmental staff to
determine whether they are current, complete, and reflective of
existing duties; and
b. Identify other positions in each department that include
environmental responsibilities. Review the formal written job
descriptions for these other key line management and operating
personnel and assess whether job descriptions incorporate any
statements regarding environment-related duties and
responsibilities.
2) Performance standards used in the performance appraisal process include
the environmental aspects of individual job responsibilities, including line
management responsibilities for environmental performance.
Environmental factors are given comparable emphasis to safety and
productivity factors:
a. Determine whether explicit measures of performance have been
identified for specific jobs, including both environmental staff and
line management personnel;
b. Determine whether environmental criteria receive substantially less
emphasis than other criteria such as productivity and safety; and
c. Determine whether periodic staff performance reviews include
explicit measures of environment-related job performance. Note
examples of environmental performance criteria used.
3) Good environmental performance is rewarded in practice, and poor
performance is penalized:
a. Identify reward, incentive or bonus systems (financial or
nonfinancial) for environmental staff and other personnel with
environmental responsibilities;
b. Determine what actions are taken for poor environmental
performance; and
c. Identify other methods used for praise or corrective action, such as
verbal feedback, memorandums, internal announcements, etc.
C. Environmental Training Programs
1) Environmental training programs are defined in controlled documents
such as a training program manual:
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a. Understand how environmental training requirements are
determined and where they are explicitly identified, for example,
training plans;
b. Determine if a training manual or other documents describe
environmental training programs.
2) There is a process in place to identify and evaluate environmental training
needs for all personnel. These needs are incorporated into individual
professional development plans:
a. Determine whether the organization has assessed its environmental
training needs, including type of training and staff requiring it;
b. Determine whether environmental skill training requirements (e.g.,
regulatory hazardous materials handling, emergency and spill
response) have been identified for all job classifications where
employees' work activities can affect environmental performance;
c. Determine whether environmental training is included in job
descriptions and/or individual professional development plans, and
d. Determine how the organization ensures that employees receive the
necessary training at appropriate intervals.
3) The environmental training program is supported by appropriate training
materials and qualified trainers:
a. Review training materials, and determine whether the materials
(e.g., written, audiovisual) are appropriate and adequate to the
purpose; and
b. Review resumes of trainers, and determine whether the trainers
have the appropriate educational background and experience for the
particular training they deliver.
4) There is a formal process to ensure that training courses are developed at
an appropriate depth and provide adequate coverage of Federal and state
regulations and internal policies and procedures:
a. Develop an understanding of the process for ensuring that all
relevant regulatory requirements are covered in training courses.
5) All levels of personnel ~ from operators to lower, middle, and upper
management — undergo some level of environmental awareness training
(linkage with Section 34):
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a. Determine who receives environmental awareness training;
b. Determine whether environmental awareness training is given to all
line personnel whose activities may impact environmental
management and compliance, as well as to their supervisors;
c. Determine what environmental training and awareness activities, if
any, the organization specifically directs toward middle and upper
level management; and
d. Determine whether contractors are included in awareness training.
6) Environmental protection training is included in new employee and
contractor orientation training, and environmental protection training
requirements have been established for temporary employees and visitors:
a. Determine whether the organization routinely conducts a formal
orientation program for all new employees and contractors, and
assess the adequacy of the training content; and
b. Review training records to determine if all new employees and
contractors have attended orientation training.
7) Training activities are documented and the training recordkeeping system
is auditable, complete, and current:
a. Determine how the organization maintains employee environmental
training records and who is responsible for this activity;
b. Identify certain training required by regulations (e.g., hazardous
waste training), and determine whether all individuals performing
these tasks have had the necessary training;
c. Select a sample of environmental and nonenvironmental employees
and review training records to determine if they are accurate,
complete, and current;
d. For these same individuals, compare actual training completed with
training needs identified for their position or in their individual staff
development plan; and
e. Assess whether the training recordkeeping system is easily
accessible, complete, and current.
8) There is a formal documented process for the periodic evaluation of the
effectiveness of training programs:
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a. Determine whether and how evaluations of the training program are
conducted;
b. Review the results of the latest evaluation, and check changes made
in response to the evaluation;
c. Interview selected personnel regarding their training, and determine
the retention level of their training; and
d. Determine whether training feedback mechanisms (e.g., tests, course
feedback forms) are provided to evaluate effectiveness of training.
D. Staff Development Opportunities
1) The organization provides career opportunities and advancement for
environmental staff within the program, where possible, or in other
programs/facilities:
a. Determine whether well-established career paths exist within the
environmental management function. Identify these paths, and
determine whether they can lead to top management positions or
whether they eventually reach "dead-ends;"
b. Identify line positions that are of the same government grade (or
that are shown in the organization's hierarchy to be at the same
organizational level) as the various environmental support positions;
c. Determine whether environmental support personnel and these "line
peers" are considered equally eligible for lateral job changes that
provide breadth of experience, and for advancement up the
organization's management ladder. To gather evidence, ask senior
management, line management, supervisors of environmental
support personnel, line personnel, and environmental support
personnel; and
d. Identify any middle or senior management staff that have
environmental support experience.
2) In staff development efforts, environmental support staff are encouraged
to acquire management and professional skills to build their supervisory
and management potential:
a. Through interviews with environmental support staff, determine
whether they are encouraged and given opportunities to acquire
management skills; and
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b. Compare training records of environmental support personnel and
"line peers" to determine whether training in skills necessary for
management-level promotions are offered equally to both groups.
Examples of such training include managerial skills, supervisory
competencies, presentation techniques, media relations,
policy/program development, and negotiation skills.
3) Cross-functional training is available and encouraged to maintain and
expand staff capabilities:
a. Determine what kinds of programs exist to perform cross-functional
tasks or to move from one department to another in an effort to
expand the staff skills base.
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Phase 3
Section 39
Assessing Environmental Programs
Program Evaluation, Reporting and Corrective Action
Generic Protocol for Conducting Environmental Audits
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Phase 3
Section 39
Table of Contents
1. Performance Objective 55
2. Key Evaluative Concerns 55
3. Criteria 55
A. Self-Assessment and Appraisal Programs 55
B. Reporting and Follow-up 58
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1. Performance Objective
The organization should have self-assessment and oversight programs in place to
effectively evaluate environmental protection activities, anticipate and report
environmental concerns, and implement corrective actions. The major objective of self-
assessment programs is to establish accountability and excellence at the "grassroots" level,
thereby involving people who are the most familiar with the operations and their
management. Self-assessment is a continual line management activity that acquires,
assimilates, documents, and reports through all levels of an organization on the
effectiveness, adequacy, efficiency, and economy of its activities. Self-assessment should
establish a culture of accountability and continuous improvement as well as foster
excellence in all program activities.
2. Key Evaluative Concerns
The purpose of this audit discipline is to evaluate programs that assess the design
adequacy and implementation effectiveness of environmental protection systems as well as
the reporting and follow-up activities associated with these appraisals. Program evaluation
includes a review of all major audits, appraisals, and self-assessments. It does not include
routine inspections, which are addressed in the Formality of Programs section of this
protocol.
Programs will be evaluated on the basis of their design and implementation to ensure
adequate breadth and depth of coverage. Reporting and followup will be assessed for
adequacy of formal systems to clearly communicate, in a timely fashion, the results of the
reviews to appropriate levels of management. Finally, the system for periodic trends
analysis of all findings to identify underlying programmatic and management deficiencies
will be evaluated.
3. Criteria
A. Self-Assessment and Appraisal Programs
The depth of detail required and the magnitude of resources expended for self-
assessment should be commensurate with the element's relative importance to
environmental compliance and/or other facility-specific requirements. Self-
assessment should incorporate both internal self-assessments and independent
technical and management appraisals.
1) Facilities and departments have implemented on-going formal, written
programs that include both internal assessments and independent
oversight appraisals:
a. Determine whether these programs include appropriate
elements/components, such as:
formal program charter;
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comprehensive scope;
defined schedules;
standard operating procedures for self-assessment;
formal reporting system;
root cause analysis;
formal corrective action system;
formal process to identify trends;
formal mechanisms to communicate root causes, trends, and
lessons learned throughout the organization;
formal self-assessment training program;
full cooperation with external oversight or assessment
organizations; and
line management-fostered atmosphere of continual self-
evaluation and quality improvement.
b. Determine whether the organization has a formal, documented
environmental self-assessment program;
c. Determine whether the program covers compliance with internal
policies and procedures, applicable governmental laws and
regulations, and best management practices;
d. Determine whether subordinate offices and facilities have a self-
assessment program;
e. Identify the environmental programs (e.g., air, surface water,
drinking water, groundwater, hazardous and solid waste, etc.) that
are evaluated in self-assessments;
f. Determine responsibilities, frequency, and process for conducting
self-assessments; and
g. Determine whether self-assessment activities are integrated both
within the line organization and across staff functions to ensure a
comprehensive self-assessment process.
2) Responsibilities and authorities for self-assessment activities are clearly
defined (linkage with Section 35):
a. Determine who is responsible for implementing the self-assessment
and appraisal programs;
b. Determine if these individuals are sufficiently independent and have
enough authority to effectively perform this responsibility; and
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c. Determine whether organizational staff are specifically dedicated to
environmental appraisals or, if not, how the organization staffs
appraisals.
3) Frequency of self-assessments and appraisals is congruent with the
program's goals:
a. Determine how frequently self-assessments and appraisals are
conducted and how the organization determines frequency schedule;
and
b. Assess whether this frequency is sufficient to meet program goals.
4) Focused functional appraisals are conducted on specific issues to reduce
the organization's long-term environmental liabilities (linkage with
Section 40):
a. Determine whether the organization has a system to identify
problem areas that require focused assessments;
5) Audits/appraisals are conducted by professionals who are trained and
qualified:
a. Determine how assessors are selected and what qualifications or
criteria are used in the selection process.
6) Audits/appraisals are conducted using formal, written guidance
documents and are documented:
a. Determine whether guidance documents, audit protocols, checklists,
and other tools are used in the preparation and conduct of the self-
assessments and appraisals; and
b. Determine whether notes are taken during the audits and retained
for future reference.
7) Self-assessment program implementation is addressed in budget planning
and budget requests (linkage with Section 40):
a. Determine whether environmental self-assessments have been
factored into strategic planning in terms of resource and budgetary
requirements.
8) The systems used for environmental program evaluations are periodically
critiqued and modifications are made as necessary:
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a. Determine what system is in place to review environmental program
evaluations;
b. Determine how often these programs are evaluated; and
c. Identify changes made to the assessment program as a result of
program review.
B. Reporting and Follow-up
1) Assessment results are documented in formal reports distributed in a
timely manner to appropriate levels of management:
a. Identify all self-assessments and appraisals that have been conducted
over the last few years and determine if reports were prepared; and
b. Review past self-assessment and appraisal reports. Identify level of
reporting detail and individuals on distribution list. Assess whether
reports reach high enough levels of management and wide
distribution to related functions (e.g., legal, engineering, etc.). Assess
whether reports provide adequate detail.
2) Corrective actions to address root cause of findings are developed and
implemented by line management:
a. Determine how corrective actions are prioritized;
b. Determine that corrective action plans are approved by both the
oversight group and senior management prior to implementation;
and
c. For each self-assessment/appraisal that has been conducted,
determine if a corrective action plan was developed by the
appropriate department, approved by management, and
implemented.
3) Corrective actions are independently tracked to ensure their completion,
objectively verified at completion, and formally closed out:
a. Determine whether the organization and field offices have a system
to track progress of corrective actions; and
b. Assess the adequacy of progress on existing corrective action plans.
4) "Lessons learned" programs are implemented to seek out improvement
opportunities for environmental performance:
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a. Determine whether the organization has developed a program or
system for learning from past problems and sharing this information
across the organization.
5) Trend analysis of findings is conducted on a periodic basis to identify
underlying programmatic or management root causes:
a. Determine if any trend analysis is conducted and how frequently;
and
b. Review the results of these analyses and inquire about actions taken
to correct root causes.
6) Performance indicators for environmental protection have been defined
and are tracked and analyzed for trends:
a. Determine what performance indicators have been established; and
b. Determine how performance indicators are tracked and analyzed for
trends.
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Phase 3
Section 40
Assessing Environmental Programs
Environmental Planning and Risk Management
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Phase 3
Section 40
Table of Contents
1. Performance Objective 62
2. Key Evaluative Concerns 62
3. Criteria 62
A. Environmental Planning and Budgeting 62
B. Risk Management 65
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1. Performance Objective
The organization should plan for environmental management activities to ensure that
environmental resources needs are adequately addressed and the organization's
environmental goals can be met. Planning for environmental protection should be
integrated with planning for other organizational functions.
The organization should have a formal system to identify environmental hazards,
assess the resulting environmental risks of those hazards, and mitigate risks.
2. Key Evaluative Concerns
This assessment discipline focuses on the environmental planning and risk
management processes. It evaluates the extent to which technical and financial planning
related to environmental management is conducted and integrated into overall
organizational planning. In addition, this discipline addresses the organization's system
for identifying, assessing, and addressing potential environmental risks, including risk
management program design and approach, issues identification, and management
involvement.
3. Criteria
A. Environmental Planning and Budgeting
1) Environmental planning is conducted with comparable formality to
planning for other organizational functions and includes both short- and
long-term planning:
a. Determine the extent to which environmental planning decisions
result from a formal, organized planning process;
b. Determine the frequency of formal environmental planning and the
planning horizon (e.g., one year, five years, 10 years);
c. Compare how staffing and budgetary requirements for the
environmental management function and other organizational
functions are determined;
d. Determine whether environmental planning is viewed as a strategic
element in the organization's long-term success;
e. Determine whether the facility has a system to identify projects
planned in the next year or two that will need NEPA review;
f. Determine whether the agency's Environmental Plan is developed in
accordance with EPA guidance contained in Federal Agency
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Environmental Management Program Planning and then forwarded
to OMB through EPA for formal review in accordance with E.O.
12088.
2) Environmental protection considerations are adequately included in
planning for other organizational functions:
a. Review strategic and/or organizational plans, annual budget
documents, proposed major capital projects, and property
acquisitions and determine whether they include environmental
considerations; and
b. Identify any recent instances where environmental concerns raised
through a program/project planning process have influenced
proposed operating plans, financial plans, or other factors.
3) Environmental issues are represented by qualified personnel in key
strategic and operations planning meetings/committees:
a. Review minutes of planning meetings to determine if environmental
personnel were involved; and
b. Determine whether environmental issues were considered in
planning meetings or activities.
4) In the planning process, the organization has a system for establishing
priorities and weighing competing factors, with environmental protection
receiving equal weight to production:
a. Assess whether priority setting (i.e., selecting projects for budget)
reflects environmental excellence goals;
b. Investigate environmental projects that have been delayed or
canceled, and determine if these projects received equal
consideration to other projects;
c. Determine whether plans for environmental management take into
account and adequately reflect the implications of proposed
operating and financial plans and initiatives; and
d. Assure that all environmental projects are reviewed to ensure that
assigned priorities reflect guidance issued by EPA in Federal Agency
Environmental Management Program Planning and are reported to
OMB in the agency's annual plan.
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5) Commitment of funds for environment-related activities is satisfactory to
serve the organization's environmental performance goals, through both
capital and maintenance projects:
a. Compare capital budget requests and annual budget allocations for
environmental programs/projects to determine whether adequate
funds have been committed to environmental protection; and
b. Determine whether all environmental items, including staff and
technical resources, have been identified in budget requests.
6) Environmental protection is an integral part of the budget and planning
process:
a. Review budget requests and allocations for line operations and other
functional areas to determine if they include environmental costs;
b. Determine whether environmental concerns are taken into
consideration in budget decisions; and
c. Ensure that all project funding necessary to comply with
environmental standards is included in the agency's budget plans
and reported in the annual agency OMB environmental plan to EPA
in accordance with Federal Agency Environmental Management
Program Planning guidance.
7) The organization has assessed its needs for pollution control technologies
and other technical equipment to achieve its performance goals:
a. Determine how the organization assesses its technical equipment
needs to maintain compliance and reduce risks;
b. Identify programs or systems that keep the organization updated on
the latest pollution control technology and ensure that best available
technology is used for maintaining compliance and reducing risks;
and
c. Determine whether environmental excursions and noncompliances
are analyzed to identify whether technology can be improved to
eliminate or reduce similar episodes in the future.
8) The organization has a system in place for the control and oversight of
purchased materials, equipment, and services supporting environmental
protection activities to ensure that they meet environmental specifications:
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a. Determine how the organization ensures that new chemicals,
equipment and/or contractors meet regulatory requirements and
comply with organizational policies on environmental protection.
B. Risk Management
1) A formal environmental risk management program has been established
and is operational. This program includes objectives, approach,
procedures, and risk evaluation criteria:
a. Identify the elements of the organization's risk management
program, and determine if the program is complete; and
b. Review internal guidelines or criteria, quantitative or qualitative,
used to determine whether a particular environmental risk arising
out of operations would be deemed "acceptable" or "unacceptable".
2) A formal, systematic review of the organization's operations/activities is
periodically conducted to identify and manage environmental risks:
a. Develop an understanding of and assess the process used to evaluate
risks;
b. Determine how often and by whom these reviews are conducted, and
c. Determine what actions have been taken to mitigate or manage
identified risks.
3) The organization has developed programs or standards to manage
environmental risks not covered by regulatory requirements (linkage to
Section 35):
a. Identify examples of how risk assessment has led to the development
or enhancement of environmental protection programs.
4) All new projects, programs, or activities that may impact the environment
are carefully reviewed to identify and address environmental risks as
early as possible. A formal project/program review and approval process,
which includes environmental considerations, has been established:
a. Besides NEPA, identify what types of projects are reviewed for
environmental performance/impact (e.g., capital projects, R&D
projects, facility-level maintenance modifications);
b. Determine whether these reviews are performed only under certain
circumstances or routinely for all projects;
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c. Determine the focus of the reviews and whether the project may
raise any significant environmental compliance issues or lead to any
potentially significant environmental risks;
d. Determine whether project environmental reviews typically follow a
standard approach and whether there is any formal guidance on the
approach;
e. Identify the criteria used for assessing the impacts of a project (e.g.,
dollar value, project type, etc.); and
f. Review records or files of environmental reviews that have been
performed.
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Phase 3
Protocol for Conducting Environmental Management
Assessments of Federal Facilities/Organizations
Appendix
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Appendix- Selecting Documents to Review and Individuals to Interview for
Environmental Management Assessments
The following discussion provides suggestions, by protocol discipline, for the most useful types
of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
Organizational Structure
The following types of individuals should be interviewed for this protocol area:
• Representatives from the agency as well as subcontractors to determine roles,
responsibilities, reporting relationships, authorities, and level of coordination;
• EHS staff and top management at the facility to determine the reporting "distance"
between the person with primary responsibility for environmental support and the overall
management of the organization and to assess the appropriateness of layers of management
and span of control; and
• EHS and line staff to understand the functional relationship of EHS to other parts of the
organization and to determine the organizational stature of the EHS office within the
organization.
The following types of documents should be reviewed:
• Documents that define organizational responsibility, authority, or accountability for
environmental programs
• Organization charts
• Position or job descriptions for line and staff personnel
• Environmental planning documents
• Formal measures used in assessing job performance
Environmental Commitment
The following types of individuals should be interviewed for this protocol area:
• Top management to determine level of knowledge, personal involvement in environmental
affairs, and inclusion of environmental issues in routine senior management meetings;
• Management and line staff at all levels and across all functional areas to determine level
of environmental commitment, sense of "ownership" of environmental protection, degree
to which environmental policies are distributed and understood, and allocation of human,
financial, and technical resources; and
• Staff in non-environmental specialty areas to determine the level of general environmental
awareness.
The following types of documents should be reviewed:
• Environmental planning documents
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• General environmental policy statements
• Issue-specific policies addressing focused environmental concerns
• Environmental program descriptions and implementation plans
• Senior management statement of support for environmental programs, including reports,
speeches, and newsletters
• Accounts of employee or organization involvement in or work with environmental task
forces, environmental professional associations, or local community organizations
• Samples of routine environmental reports to upper management
• Minutes of senior management meetings
Environmental Protection Programs
The following types of individuals should be interviewed for this protocol area:
• EHS staff and line management as well as subcontractors to determine level of
development or implementation of environmental programs or plans
The following types of documents should be reviewed:
• Environmental program plans required by the agency
• Environmental monitoring and surveillance plans
• Source and emission inventories for air and water pollution control
• NESHAPs agreement
• Toxic and chemical materials management plan
• Emergency response and remedial action plan
• Environmental incident reporting procedures
• Preventative maintenance and inspection procedures
• Reports to management or regulatory agencies
Formality of Environmental Programs
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible for tracking agency requirements and relevant environmental
regulations to determine if the organization is up-to-date on new, proposed, and emerging
regulatory issues;
• Personnel responsible for the development and implementation of procedures and
standards to determine the level of congruence with the agency's conduct of operations
policy;
• Personnel responsible for conducting routine site walk-through inspections and'following-
up on inspection findings to determine adequacy of the system; and
• Personnel responsible for record-keeping and document control to assess the document
control system
The following types of documents should be reviewed:
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• Policies and procedures relating to project and field office implementation of
environmental requirements
• Environmental protection plans
• Standard operating procedures for the site
• Regulatory tracking protocols and procedures
• Inspection checklists and logs
• Examples of a variety of environmental records and reports, including incident and
environmental performance reports
Internal and External Communication
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible for communication of environmental information (e.g., goals,
performance, policies, and procedures) to understand how formal and informal
communication channels are used
• Management and line staff'to determine extent to which environmental information is
distributed within the organization
• Important external stakeholders, such as environmental groups, state and Federal
environmental regulators, and management to determine extent of communication with and
knowledge of the facility
The following types of documents should be reviewed:
• Samples of the scope of environmental management reports
• Staff meeting minutes
• Internal newsletters which contain environmental information
• Forms and guidelines for internal anonymous reporting of environmental issues
• Documentation of information provided to and awareness programs for external
stakeholders
• Press releases relating to environmental issues
Staff Resources, Training, and Development
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible for securing an adequate level of environmental staffing to
understand to assess the system to identify short- and long-term environmental staffing and
resource requirements;
• A sample of management and line staff at all levels of the organization to determine if
there is an adequate level of staffing for environmental functions and to determine the level
of environmental training throughout the organization;
• Training office personnel to assess the training program and the process to evaluate and
establish the organization's training needs; and
• Career development office personnel to identify career opportunities for environmental
staff.
The following types of documents should be reviewed:
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• Documents requests and justifications for additional staff with environmental
responsibilities
• Hiring plans
• A sample of resumes for environmental and non-environmental staff who have
environmental responsibilities
• Training program manuals
• Training records for a range of individuals within the organization, including
environmental support personnel and their "line peers"
• Job descriptions and performance criteria for line management and operating personnel
• Individual professional development plans
Program Evaluation, Reporting, and Corrective Action
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible for conducting and/or managing the self-appraisal process to assess
the design of the process
• Top management to determine how self-appraisal information is used within the
organization
• A sample of managers and line staff responsible for implementing corrective actions
The following types of documents should be reviewed:
• Formal descriptions of the oversight program or process, including responsibilities of key
staff
• Self-appraisal program budget allocation
• Audit and appraisal reports
• Corrective action plans
• Documentation of follow-up activities for corrective actions
• Trend analysis and performance indicator reports
Environmental Planning and Risk Management
The following types of individuals should be interviewed for this protocol area:
• Environmental planning personnel to evaluate budgeting, priority-setting and allocation of
resources activities
• Staff with the budgeting office to determine if environmental planning is integrated with
other organizational planning functions (e.g., development of operating and capital
budgets)
• Risk management personnel to evaluate the adequacy of systems to identify and minimize
environmental hazards
The following types of documents should be reviewed:
• Short- and long-term business plans and strategic plans
• Formal risk management documents, such as readiness review plans or risk assessments
• Environmental risk tracking and trending reports
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