NSI Special Bulletin 01/05 1 of 14 Dated: 5 th January 2005 To: EMS Gold Applicants and Approved Companies SPECIAL BULLETIN No. 01/05 Guidance and clarification of NSI requirements for the implementation of BS EN ISO 14001: 2004, the British, European and International Standard for Environmental management systems – Requirements with guidance for use (Supersedes BS EN ISO 14001:1996) BS EN ISO 14001:2004 shows a publication date of the 16 th November 2004 and is now available through licensed outlets including the NSI who can supply copies at a discounted rate. BS EN ISO 14001:2004 will now be applied to the NSI EMS Gold Scheme as a condition of NSI approval. The Standard will be applied with immediate effect, subject to the additional clarifications and guidance within this Special Bulletin. With immediate effect Applicant Companies will be assessed against the 2004 Edition and any Non-Compliances recorded against clauses of the Standard will have to be satisfactorily addressed before approval can be granted. NSI Approved Companies will however be given until the 15 th May 2006 to fully comply with the amended requirements such that there is an 18 month transition period as referenced in the National foreword to the Standard. In the interim, observation reports will be issued for any of the revised requirements that are not satisfied and if such observations are not adequately addressed by the 15 th November 2004 they will be elevated to Non-Compliances. Failure to then close-out any Non-Compliances by the end of the transition period i.e. the 15 th May 2006 will mean that a certificate to BS EN ISO 14001:2004 cannot be generated and existing certification to BS EN ISO 14001:1996 will also cease. Certificates for existing NSI Approved Companies will be updated as and when compliance with the new edition is demonstrated. Applicant companies should read this Special Bulletin in conjunction with the NSI Quality Schedule EMSQS 101 which provides further guidance and clarification on the application of BS EN ISO 14001:2004 within the Security and Fire Industry. NSI Special Bulletin 01/05 2 of 14 SUMMARY OF KEY CHANGES (Highlighted under the clauses of the new Standard) Comments under each clause consist of a summary of the changes when compared with the corresponding clause within BS EN ISO 14001:1996 and where relevant any specific NSI requirements are also detailed. Where the actual wording is quoted it is reproduced in bold text. Where it is considered relevant to further clarify the specified requirement, additional guidance is included in italics. It is not, however, the intent of the NSI to only impose its own recommended methods of compliance with specified requirements and the NSI will give full consideration to any alternative methods of achieving compliance with specified requirements. FRONT PAGE Although the header through the bulk of the document is reproduced as EN ISO 14001:2004, the front sheet makes it clear that EN ISO 14001:2004 has the status of a British Standard. NATIONAL FOREWORD The foreword makes it clear that the British Standard is the official English language version of EN ISO 14001:2004, is identical with ISO 14001:2004 and supersedes BS EN ISO 14001:1996 which is now obsolescent. It then makes it clear that there is an internationally agreed phased transition period of 18 months for implementing ISO 14001:2004 to facilitate the transition during the normal certification cycle. A reminder is included that compliance with a British Standard does not of itself confer immunity from legal obligations . There has been significant adverse press on the value obtained from certificated Environmental Management Systems particularly as certain surveys do not apparently indicate any difference in the level of prosecutions for breaches of environmental legislation between companies with a certificated EMS and those without. In many respects the surveys and conclusions have attracted heavy criticism as they do not appear to make any distinction between certificates issued by UKAS Accredited Bodies and Unaccredited bodies, however the debate has generated appropriate discussion on the degree of assurance that a certificated EMS can give in terms of legal compliance and the extent of any legal compliance evaluation that should be carried out by independent auditors before an EMS can be certificated. NSI Special Bulletin 01/05 3 of 14 NATIONAL FOREWORD (Continued) Such concerns have been to a degree taken into account in the revision process for ISO 14001 and have resulted in changes to clauses 4.3.2 Legal and other requirements and 4.5.2 Evaluation of compliance. The NSI Guidance to the referenced clauses also takes note of the November 2004 issue of the UKAS (United Kingdom Accreditation Service) C3 Document, ‘General principles for the Assessment of Certification Bodies for Environmental Management System Certification’ which has be en introduced by UKAS as part of an initiative to restore confidence in Accredited EMS certification. INTRODUCTION The second paragraph reference to environmental reviews and audits is retained. The fourth paragraph now gives more emphasis to the provision of requirements for an environmental management system to enable an organisation to develop and implement a policy and objectives, which take into account legal requirements and information about significant environmental aspects. Although there is not a specific requirement to conduct a comprehensive initial environmental review before developing an environmental policy, objectives, targets and programme, it is a sensible starting point and probably the best way to identify and list the significant aspects or issues that the organisation can control or influence. Such a review would entail reviewing all processes carried out with particular emphasise on the identification of any waste streams or emissions to air, water or land. When reviewing all processes carried out particularly those involving installation or maintenance of equipment both normal and abnormal conditions should be considered including any emergency situations that could conceivably arise. A new fifth and sixth paragraph is added to make it clear that the second edition of the Standard focuses on clarification of the requirements originally set out in the first edition and to give more consideration of the provisions of ISO 9001(2000) to enhance the compatibility of the two standards for the benefit of the user community. (Annex B now contains updated tables showing the correspondence between ISO14001:2004 and ISO 9001:2000 which may be useful for those organisations endeavouring to document a fully integrated management system). The remainder of the introduction retains the references to the PDCA (Plan-Do-Check-Act) methodology that the standard is based upon but also gives more emphasis to the required commitment to comply with applicable legal requirements and with other requirements to which the organisation subscribes, to prevent of pollution and to continual improvement. A new final paragraph makes it clear that the level of detail and complexity of the environmental management system, the extent of documentation and the resources devoted to it depend on a number of factors, such as the scope of the system, the size of an organisation and the nature of its activities, products and services. This may be the case in particular for small and medium – sized enterprises. NSI Special Bulletin 01/05 4 of 14 INTRODUCTION (Continued) NSI will take such detail into account and although the fundamentals to be addressed are essentially the same for any organisation, it is accepted the complexity of the EMS may vary considerably dependent upon the product or service provided e.g. a private prison which is effectively a small secure community with all sorts of waste streams will typically have a whole range of issues to address such as disposal of special and clinical waste, power generation etc and the extent of relevant legislation and stakeholder/interested parties views that need to be taken into account will be extensive. Contrast this with a family owned small to medium sized guarding company that places personnel on client’s sites and the range of issues that it can control and influence will be considerably less, with the main opportunities for improvement in its environmental performance often limited to its office based activities and transportation. Somewhere in the middle in terms of complexity will be the small to medium sized installer of electronic security systems who will have to consider the impact of specific legislation such as the European Union’s Directives on Waste Electrical and Electronic Equipment (WEEE) and may also need to demonstrate an awareness of the Directive on the Restriction of the use of certain Hazardous Substances (RoHS) in Electrical and Electronic Equipment when sourcing new components. The range of issues to be addressed by organisations wishing to have their EMS Approved by NSI will also be influenced by NSI policy to only target its EMS certification at existing clients within the Security and Fire Industries in line with the range of services and products already encompassed within its schemes already Accredited for QMS (Quality Management Systems) Certification. 1. SCOPE The existing sub-clauses c, d and e have been reworded and expanded upon as four numbered methods of demonstrating conformity with the standard under a new clause c). Point 4 is the one relevant to certification with the NSI i.e. an organisation applying for certification by the NSI is seeking certification/registration of its environmental management system by an external organisation. The requirement for the scope of any application of the Standard to be clearly identified has been deleted as it now gets more focus under clause 4.2 Environmental policy. 2. NORMATIVE REFERENCES No normative references are cited and the clause has been retained to retain the identical numbering with the previous edition. NSI Special Bulletin 01/05 5 of 14 3. TERMS and DEFINITIONS A significant number of the definitions have been reworded to provide greater clarity and some additional ones have been included. 3.1 A new definition is included for ‘auditor’ i.e. person with the competence to conduct an audit. This links to the requirement under clause 4.5.5 for internal audit and clause 4.4.2 on competence, training and awareness. In order to satisfy this requirement records need to be maintained to verify that the designated individuals are competent on the basis of appropriate education, training or experience and it will normally be expected that internal auditors will have received some formal training in auditing techniques and awareness of environmental issues and also conducted some audits under the guidance of a more experienced auditor before being deemed competent to conduct audits on their own. 3.1 The definition for ‘continual improvement’ has been modified and is now defined as the recurring process of enhancing the environmental management system in order to achieve improvements in overall environmental performance consistent with the organisation’s environmental policy. 3.2 A definition is now included for ‘corrective action’ i.e. action to eliminate the cause of a detected nonconformity. 3.3 A definition is now included for ‘document’ i.e. information and its supporting medium with Note 1: The medium can be paper, magnetic, electrical or optical computer disc, photograph or master sample, or a combination thereof and Note 2: Adopted from ISO 9000:2000 clause 3.7.2. 3.7 The definition for ‘environmental impact’ has been modified and is now defined as any change to the environment whether adverse or beneficial, wholly or partially resulting from an organisations environmental aspects. 3.8 The definition for ‘environmental management system (EMS)’ has been modified and is now defined as part of an organisations management system used to develop and implement its environmental policy and manage its environmental aspects. Two notes are also included which are generally compatible with the additional text that was in the original definition i.e. Note 1 states that A management system is a set of interrelated elements used to establish policy and objectives and to achieve those objectives ’ and Note 2 states that ‘ A management system includes organisational structure, planning activities, responsibilities, practices, procedures, processes and resources. NSI Special Bulletin 01/05 6 of 14 3.9 The definition for ‘environmental objective’ has been modified and is now defined as the overall environmental goal, consistent with the environmental policy, that an organisation sets itself to achieve . Although the requirement for the objective to be quantified where practicable has been dropped from the definition it is still sensible to link certain objectives to actual environmental targets e.g. an overall environmental objective of reducing energy consumption may be linked to specific percentage reductions that are targeted to be achieved by certain dates, this then enables actual progress to be more accurately determined. It should also be noted that the relevant clause within the standard maintains the linkage i.e. clause 4.3.3. Objectives, targets and programme(s) still requires objectives and targets to be measurable, where practicable etc. 3.10 The definition for ‘environmental performance’ has been modified and is now defined as the measurable results of an organisations management of its environmental aspects , followed by an explanatory note that states that in the context of environmental management systems, results c an be measured against the organisation’s environmental policy, environmental objectives, environmental targets and other environmental performance requirements. 3.11 The definition for ‘ environmental policy’ has been modified and is now defined as the overall intentions and direction of an organisation related to its environmental performance as formally expressed by top management , followed by an explanatory note that states that the environmental policy provides a framework for action and for setting of environmental objectives and environmental targets . 3.12 Under the definition for ‘environmental target’ the requirement for the detailed performance requirement to be quantified where practicable has been dropped (see however additional comments under 3.9 above and clause 4.3.3. Objectives, targets and programme(s). 3.14 A definition for ‘internal audit’ has been included i.e. systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which the environmental management system audit criteria set by the organisation are fulfilled. A Note is then included that recognises that in many cases, particularly in smaller organisations, independence can be demonstrated by the freedom from responsibility for the activity being audited. 3.15 A definition for ‘nonconformity’ is now included i.e. non-fulfilment of a requirement. This equates to Non-Compliances and Major Non-Compliances in NSI terminology. Please note however that NSI has a lower level of report that also needs a corrective action response i.e. Observation Reports. 3.17 A definition for ‘preventive action’ is now included i.e. action to eliminate the cause of a potential nonconformity. NSI Special Bulletin 01/05 7 of 14 3.18 The definition for ‘prevention of pollution’ has been modified and is now defined as the use of processes, practices, techniques, materials, products, services or energy to avoid, reduce or control (separately or in combination) the creation, emission or discharge of any type of pollutant or waste, in order to reduce adverse environmental impacts. An explanatory Note is also included to make it clear that prevention of pollution can include source reduction or elimination, process, product or service changes, efficient use of resources, material and energy substitution, reuse, recovery, recycling, reclamation and treatment. 3.19 A definition is now included for ‘procedure’ i.e. a specified way to carry out an activity or a process , with two notes that make it clear that it can be documented or not and that the definition is adapted from ISO 9000:2000, 3.4.5. 3.20 A definition is now included for ‘record’ i.e. document stating results achieved or providing evidence of activities performed. 4 ENVIRONMENTAL MANAGEMENT SYSTEM REQUIREMENTS 4.1 General requirements The general requirements have been expanded to make it clear that not only should an EMS be established and maintained but that the organisation shall document, implement and continually improve an EMS and determine how it will fulfil the requirements of the Standard. An additional sentence is also added to make it clear that the organisation shall define and document the scope of its environmental management system. The above principles have always been generally understood and applied; the main change is that there is now a more precise or additional clause that the auditor can reference if there is any failure to effectively document, implement, continually improve or fulfil the requirements of the standard. The scope of the environmental management system shall be included as part of the environmental policy (statement). 4.2 Environmental policy Minor changes have been made to the opening sentence to stress that the listed requirements should be addressed within the defined scope of the organisations EMS . Item c) now references ‘applicable legal requirements’ rather than ‘relevant environmental legislation and regulations’. NSI Special Bulletin 01/05 8 of 14 4.2.1 Environmental policy (Continued) The latter part of item e) has been incorporated as a new item f) and amended from ‘all employees’ to ‘all persons working for or on behalf of the organisation’. The new wording is a sensible and additional reference to remind organisations that subcontractors working for or on behalf of the organisation also normally need to be aware of the Environmental Policy, in the same way that they should be made aware of the organisations Health & Safety Policy. There may also be additional personnel who could in some respects be considered as working for the organisation e.g. trustees in a prison who could be involved with initial segregation of waste material or energy reduction programmes. 4.3 Planning 4.3.1 Environmental aspects The revised text now requires organisations to identify the environmental aspects of its activities, products and services that it can influence (rather than over which it can be expected to have an influence) taking into account planned or new developments, or new or modified activities, products and services. The latter part brings in the reference to projects that was previously part of clause 4.3.4 the environmental management programme. An additional sentence is also incorporated to emphasise that the organisation shall ensure that the significant environmental aspects are taken into account in establishing, implementing and maintaining its EMS. 4.3.2 Legal and other requirements There is now more emphasis on determining how the applicable legal requirements relate to the identified environmental aspects and to ensure that the applicable legal requirements and other requirements that the organisation subscribes to are taken into account in establishing, implementing and maintaining the EMS . Also in the month that the 2004 edition of BS EN ISO 14001 was issued, UKAS also issued a new document identified as ‘C3’ that covers the ‘General Principles for the Assessment of Certification Bodies for Environmental Management System Certification’. This document has been introduced to address widespread concern regarding the degree of assurance that a certificated EMS provides with respect to legal compliance. In a nutshell this requires certification bodies to pay particular attention to the organisations procedures for identifying applicable legal requirements and determining how such requirements apply to its environmental aspects. In light of such developments NSI has reviewed its approach to verifying compliance with this clause of the Standard and shall not recommend certification until all the following requirements are satisfied: NSI Special Bulletin 01/05 9 of 14 4.3.2 Legal and other requirements (continued) 1) There shall be a detailed, documented, implemented and maintained procedure that clearly explains the methods, systems, databanks, journals etc that are regularly accessed to identify applicable legal requirements and any other requirements to which the organisation subscribes. 2) The procedure shall also detail the process(es) for determining how such requirements apply to the organisations environmental aspects. 3) The procedure shall also detail the arrangements for periodically evaluating/re- evaluating compliance with applicable legal requirements and demonstrate that if there are any subsequent and significant amendments to such requirements they are subject to timely consideration such that any potential breaches of legal requirements are immediately brought to the attention of top management. 4) A central register of applicable legislation and other requirements that the organisation subscribes to shall be maintained and it shall reference the related environmental aspects. 5) A central record of any breaches of legislation or other requirements to which the organisation subscribes to shall be maintained and there shall be a clear audit trail to verify that timely action has been or is being taken to rectify any failure to fully comply. Such records shall also show that the appropriate authorities have been informed/consulted and that the conditions of any temporary concessions or exceptions are clearly understood and communicated to relevant personnel. Note: Although NSI do not necessarily carry out a complete legal compliance evaluation, the organisations register of environmental legislation will be reviewed in sufficient depth to verify whether there are any obvious omissions. If there are significant omissions, a Non- Compliance shall be immediately raised and certification shall not be recommended until the organisation has reviewed/revised its procedures for identifying, accessing and determining the significance of appropriate legal and other requirements and rectified the omissions. If there are any current breaches of applicable legislation, registration shall not be recommended unless the appropriate authorities have granted a concession and there is an agreed action plan leading to eventual compliance. 4.3.3 Objectives, targets and programme(s) This clause merges the previous clause 4.3.3 Objectives and targets with 4.3.4 Environmental management programme(s) and includes a new paragraph as follows: The objectives and targets shall be measurable, where practicable, and consistent with the environmental policy, including the commitments to prevention of pollution, to compliance with applicable legal requirements and with other requirements to which the organisation subscribes, and to continual improvement. NSI Special Bulletin 01/05 10 of 14 4.3.3 Objectives, targets and programme(s) [continued] The above clause clarifies the sensible principles that should always have been applied and organisations should take care to ensure there is important linkage between the various documents and ensure they are not developed in isolation. For example it would not make sense to include in the Policy Statement a general commitment to reduce energy consumption and then have no specific objectives, targets or milestones to show how this is to be measured, monitored or achieved. 4.4 Implementation and operation 4.4.1 Resources, roles, responsibility and authority The title of this clause has changed in order to give more emphasis to the requirement for management to ensure the availability of resources essential to establish, implement, maintain and improve the environmental management system . The requirement for the management representative to report to top management on the performance of the EMS for review has been retained but there is now a specific requirement to include recommendations for improvement . The above is a sensible clarification and recognises that the management representative for EMS will often be best placed to review in detail information obtained as a result of the monitoring and measurement activities and identify opportunities for improvement that can then be communicated to top management for discussion and agreement at a management review meeting. 4.4.2 Competence, training and awareness This section introduces new terminology i.e. person(s) performing tasks for it or on its behalf that have the potential to cause a significant environmental impact. This is a useful change when compared with the previous text on ‘employers or members of each relevant function’ as it assists in driving home the message that the requirements may also apply to contractors, sub-contractors, temporary staff etc if there tasks have the potential to cause a significant environmental impact. 4.4.3 Communication More clarity has been given to the final paragraph of this clause and the organisation shall now decide whether to communicate externally about its significant environmental aspects, and document its decision. If the decision is to communicate, the organisation shall establish and implement a method(s) for this external communication. Methods of communication will vary considerably particularly across different sizes of organisation. NSI Special Bulletin 01/05 11 of 14 4.4.3 Communication (continued) In the case of a PLC (Public Limited Company) there may be clear requirements to communicate some detail on the organisations environmental performance in conjunction with the published accounts/annual report whereas in a small family owned company with very few significant aspects that it can control or influence, the pressures for such communication may be more limited such that it may be acceptable to only communicate externally when there is some legal compulsion to do so. 4.4.4 Documentation This clause has been brought more in – line with ISO 9001:2000 and now includes a specific list of documents that have to be maintained within the EMS i.e. the EMS documentation shall include: a) the environmental policy, objectives and targets, b) description of the scope of the EMS, c) description of the main elements of the EMS and their interaction, and reference to related documents, d) documents, including records, required by this International Standard, and e) documents, including records, determined by the organisation to be necessary to ensure the effective planning, operation and control of processes that relate to its significant environmental aspects. Requirements a) to c) inclusive may be best presented in the form of a higher level Policy Manual that addresses all clauses of BS EN ISO 14001:2004 as further interpretated by this Special Bulletin and EMSQS 101. Such a document should also provide a clear audit trail to any supporting procedures, defined processes, and work instructions etc that in turn should link to the standard proforma or records that are completed as evidence of conformity. 4.4.5 Control of documents This clause has also been brought more in-line with ISO 9001:2000 but only references a requirement for a procedure, unlike ISO 9001:2000 which requires a documented procedure. As most organisations implementing an EMS will already have a certificated QMS embracing ISO 9001:2000 then NSI shall normally expect such a detailed and documented procedure to be also applied for EMS, modified as necessary to reflect any specific requirements of ISO 14001:2004, EMSQS 101 or this Special Bulletin. 4.4.6 Operational control Although there is a slight change to the wording of the first paragraph, the requirements of this clause are essentially unchanged. NSI Special Bulletin 01/05 12 of 14 4.4.7 Emergency preparedness and response Again the requirements of this clause have not really changed but have been reworded to ensure greater clarity with respect to the need for the organisation to have a procedure to identify potential emergency situations and potential accidents that can have an impact(s) on the environment and how it will respond to them. 4.5 Checking (Previously checking and corrective action) 4.5.1 Monitoring and measurement The requirement now refers to procedures rather than documented procedures and the clause on periodic evaluation of legal compliance has been moved to clause 4.5.2. As with the text under 4.4.6 a) of the standard, a decision upon whether to maintain a fully detailed and documented procedure should be based upon consideration as to whether the absence of the same could lead to a deviation from the environmental policy, objectives and targets. In the absence of a documented procedure it can sometimes be harder to verify that there is a clearly defined and communicated procedure (practice) that is fully in tune with established policy and that can be effectively audited (both internally and externally). 4.5.2 Evaluation of compliance This is a new clause but not a new requirement and it has been made into a separate clause to emphasise the importance of periodic evaluation of legal compliance and compliance with other requirements to which the organisation subscribes. With regard to the frequency of such periodic evaluations, it makes sense to have such evaluations as an input to each management review and there has been a historic acceptance that a complete management review should take place at intervals not exceeding twelve months, with the proviso that more frequent reviews should be carried out whilst the EMS System is still relatively immature. This still assumes that if significant amendments are made to applicable legislation listed on the register, between the periodic review dates, the significant changes will be detected and evaluated in a timely manner particularly if there is an early implementation date. 4.5.3 Nonconformity, corrective action and preventive action (previously clause 4.5.2) Nonconformity is now utilised instead of non-conformance and the requirements incorporate similar wording to that utilised within ISO 9001:2000 and it therefore normally makes sense to have a common procedure to satisfy both QMS and EMS requirements. However from an EMS point of view there also needs to be emphasis on taking action to mitigate the environmental impact of any actual and potential nonconformities. NSI Special Bulletin 01/05 13 of 14 4.5.3 Nonconformity, corrective action and preventive action (continued) A Nonconformity is defined in the Standard as non-fulfilment of a requirement; a definition based upon ISO 9000:2000 Clause 3.6.2. In many respects this is easier to understand if we talk about specified requirements and the recommended higher level, policy manual should detail the various methods or systems for identifying, recording and actioning nonconformities e.g. internal and external audit, periodic evaluation of legal compliance, incident reporting including reviews carried out after accidents or emergency situations and as a result of the monitoring and measurement of processes or operations that can have a significant environmental impact. 4.5.4 Control of records (previously clause 4.5.3) In general terms the requirements have not changed significantly but are restructured to give greater clarity. The requirement to establish and maintain a procedure for the identification, maintenance and disposition of environmental records has been expanded and now reads ‘the organisation shall establish, implement and maintain a procedure(s) for the identification, storage, protection, retrieval, retention and disposal of records’. Greater clarity is also provided with respect to the type of records to be maintained by the organisation i.e. records as necessary to demonstrate conformity to the requirements of its environmental management system and of this international standard (ISO 14001:2004), and the results achieved. 4.5.5 Internal Audit (previously clause 4.5.4 Environmental management system audit) Again the clause has been more closely aligned with that in ISO 9001: 2000 and the text makes it much clearer the audit programme should be planned, established, implemented and maintained by the organisation, taking into consideration the environmental importance of the operation(s) concerned and the results of previous audits. In order to ensure that EMS audits are sufficiently robust it is essential that they are conducted by auditors who have not only received some formal training in auditing techniques but will also be able to demonstrate that they are sufficiently informed of and aware of environmental issues. It shall also be clear that the audit programme pays particular attention to the process for periodic evaluation of legal compliance and the process for establishing, implementing and maintaining appropriate objectives and targets that are consistent with the environmental policy and the commitment to prevention of pollution and to improvements in the organisations environmental performance. NSI Special Bulletin 01/05 14 of 14 4.6 Management review Top management should now review the organisations environmental management system at planned intervals rather than at intervals that it determines and it is now much clearer that the reviews shall include assessing opportunities for improvement. Again the text has come more in line with ISO 9001:2000 as it now reproduces a list of items that should be an input to the management review as well as being more prescriptive regarding the output from the review. NSI shall expect to see a clear agenda and minutes of the management review that clearly demonstrate that as a minimum items a) to h) are included as a standard topic for review/discussion and that as minimum the specified requirements in terms of output are satisfied.