Compliance with legislation and regulations
for users of environmental and/or occupational
health and safety management systems
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We at SCCM are convinced – and our experience has proven – that
any organization, large or small, will achieve better environmental
performance by using the ‘plan-do-check-act’ approach outlined in
the ISO 14001 standard.
Copyright SCCM
All rights reserved. Nothing included in this publication may be made public, and/or reproduced by means
of printing, photocopying, microfilm or any other method, without prior written permission from SCCM.
Disclaimer
Although the utmost care has been taken with this publication, errors and omissions cannot be entirely
excluded. SCCM therefore accepts no liability, not even for direct or indirect damage occurring due to or in
relation with the use of the content of this publication.
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Compliance with legislation and
regulations for users of environmental
and/or occupational health and
safety management systems
N100824, 10 july 2012
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Contents
cha p te r 1
1Background
5
cha p te r 2
2
Compliance management within the ISO 14001 and
OHSAS 18001 standards
cha p te r 3
7
3
The compliance management system in detail, by element
10
3.1
Commitment to compliance
10
3.2
Identifying legislation and regulations
11
3.3
Translating legal requirements into their impact on the organization
14
3.4
Ensuring that organizational and technical measures for meeting
the requirements are taken
3.5
Self-evaluation of compliance with legislation and regulations
18
3.6
Internal audit
20
3.7
Management review of compliance
21
cha p te r 4 4
Relationship to the other parts of the managementsystem
1
2
3
4
5
6
7
8
9
16
22
a nne xe s
Sample of a simple register of legislation and regulations for an
offset printing company
Sample applicable legal environmental and compliance requirements
Sample translation of legal environmental requirements into concrete tasks
Sample translation of general environmental requirements into specific rules
Sample of simple register of OHS legislation and regulations for an
offset printing company
Sample applicable legal OHS requirements and how to ensure compliance
Sample translation of legal OHS requirements into concrete tasks
Sample translation of general OHS requirements into specific rules
Sample management review procedure
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26
29
31
34
36
38
41
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chapter 1
Background
It is important for an organization to ensure it is complying with legislation and regulations. Organizations
are held accountable for their ‘compliance behaviour’ and non-compliance carries heavy risks. Management
wants to know if their organization is ‘in compliance’. Proper compliance with legislation and regulations is
a precondition for operating a sustainable and socially responsible business. An organization’s management
can only state with conviction that it has control of its compliance when it is working on it systematically.
Compliance with legislation and regulations is one of the basic requirements of both the ISO 14001 and
OHSAS 18001 standards. Both standards in fact contain all the elements of a ‘compliance management
system’ with which compliance can be demonstrated:
>
Identifying legislation and regulations.
>
Translating legal requirements into their impact on the organization.
>
Ensuring implementation.
>
Self-evaluating compliance.
>
Internal audits.
>
Management review of the results.
In 2008, the Dutch government launched a programme promoting innovation in supervision (‘Vernieuwing
toezicht’). One element of this programme is ‘systemic supervision’, the basic principle of which is that an
organization must have a system for adequately controlling its occupational health and safety (hereafter
OHS) and environmental risks. As a minimum, an organization must achieve the level of control laid down in
legislation and regulations. Systemic supervision emphasizes evaluating the management system, instead
of checking each individual requirement of legislation and regulations. An element of this – compliance
management – is the systematic identification and compliance with legislation and regulations.
Aim of this publication
Our objective is to help show organizations in practical terms how to interpret the requirements in the
ISO 14001 and OHSAS 18001 standards related to compliance with legislation and regulations. This booklet
provides some concrete examples, but there certainly are other ways the requirements can be worked out.
The idea is to inspire you to find an interpretation that is right for your own organization.
This document is intended as an aid, and organizations are free to use the suggestions in it or not.
EA 7/04
This document is also based on the EA 7/04 guideline ‘Legal compliance as a part of Accredited ISO 14001:
2004 certification’. This guideline was published in 2007 by the European Co-operation for Accreditation,
and must be followed by every certification body accredited in an EU member state. The document can be
found on www.sccm.nl.
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Computer programs
Every organization must document its management system and support its implementation, whether
or not using dedicated software. This booklet frequently shows the relationship with procedures and
instructions. In practice, these can be ‘automated’ by using software with the various steps built into it.
The user automatically is taken through these steps.
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chapter 2
2 Compliance management within
the ISO 14001 and OHSAS 18001
standards
Various elements of both the ISO 14001 and OHSAS 18001 standards contain direct or indirect references
to ‘compliance with legislation and regulations’. Together these elements constitute the compliance
management system. Table 1 shows the elements of the standard that make explicit reference to legislation
and regulations. Although the ‘internal audit’ element does not explicitly refer to legislation and regulations,
it is included here since the internal audit is an essential link.
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Table 1:
Compliance management related to requirements in the ISO 14001 and OHSAS 18001 standards
Co m p l i ance
Te xt o f I S O 14 0 01
C l au se n o. C l au se n o.
manag emen t e l emen t
(for most clauses identical or very similar to OHSAS 18001)
I S O 14 0 01
OHSAS
1 80 01
1
Commitment to compliance
Top management shall define the organization’s environmental policy and ensure that,
4.2 c
4.2 c
4.3.2 a
4.3.2
within the defined scope of its environmental management system, it includes a
commitment to comply with applicable legal requirements and with other requirements
to which the organization subscribes which relate to its environmental aspects.
2
Identifying legislation and
The organization shall establish, implement and maintain (a) procedure(s) to
regulations
identify and have access to the applicable legal and other requirements to which
Translating legal
The organization must establish, implement and maintain (a) procedure(s) to
requirements into impact on
determine how these legal and other requirements apply to its environmental aspects.
the organization subscribes related to the organization’s environmental aspects.
3
4.3.2 b
the organization
4
Ensuring that organizational
The organization shall ensure that these applicable legal and other requirements to
and technical measures are
which the organization subscribes are taken into account in establishing, implementing
taken in order to comply
and maintaining its environmental management system.
with the requirements
The objectives and targets shall be measurable, where practicable, and consistent
4.3.2
4.3.2
4.3.3
4.3.3
4.4.6
4.4.6
4.5.2.1
4.5.2.1
4.5.5
4.5.5
4.6
4.6
with the environmental policy, including the commitments to prevention of pollution,
to compliance with applicable legal requirements […].
The organization shall identify and plan those operations that are associated with
the identified significant environmental aspects in line with its environmental policy,
objectives and targets, in order to ensure that they are carried out under specified
conditions […].
5
Self-assessing compliance
Consistent with its commitment to compliance, the organization shall establish,
implement and maintain a procedure(s) for periodically evaluating compliance with
applicable legal requirements. The organization shall keep records of the results of
the periodic evaluations.
6
Internal audit
The organization shall ensure that internal audits of the environmental management
system are conducted at planned intervals to
a) determine whether the environmental or OHS management system conforms to
planned arrangements, and has been properly implemented and is maintained, and
b) provide information on the results of audits to management.
7
Management review of
Reviews shall include assessing opportunities for improvement and the need for
compliance
change to the environmental management system, including the environmental policy
and environmental objectives and targets. Input to management reviews shall include:
>
results of internal audits and evaluations of compliance with legal requirements
and other requirements to which the organization subscribes, and
>
changing circumstances, including developments in legal and other requirements related to the organization’s environmental aspects.
The elements of the standard listed in table 1 constitute the ‘core’ of the compliance management system.
Of course other elements are also relevant for achieving proper compliance (such as communication,
monitoring and measuring, and nonconformities and corrective action). They will be discussed in chapter 4.
Chapter 3 will discuss how each part of the compliance management system can be interpreted, and also
has references to other parts of the standard.
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Compliance with legislation and regulations is also an important element of the EMAS (Eco Management
and Audit Scheme) regulation. Under this regulation, companies can obtain the right to use a European
‘environmental logo’. To qualify, an organization must have an environmental management system and
draw up an annual environmental report. The EMAS environmental management system is based on the ISO
14001 standard, but has some additional requirements. An organization following the plan outlined in this
document will meet these requirements.
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chapter 3
3 The compliance management
system in detail, by element
This chapter elaborates the elements of the compliance management system. The diagrams show in a
nutshell the relationship between the step described and the steps before and after it.
3.1
Commitment to compliance
>
Identifying relevant
legislation and
regulations
§ 3.2
>
Keeping track of
changes in legislation
and regulations
§ 3.2
>
Impact of legal
requirements
§ 3.3
>
>
Commitment to
compliance
§ 3.1
Laid down in policy: the commitment to
comply with legislation and regulations
The organization’s top management must lay down its commitment to comply with legislation and
regulations in its environmental and/or OHS policy. In practice, this is done by including a text in a ‘policy
declaration’ signed by top management, in which other policy principles (such as the commitment to
improving performance) are laid down.
More important than the written statement is the way that this commitment is communicated within the
organization by its top management. It is essential that compliance with legislation and regulations is part
of the organization’s internal culture. Simply putting a statement down on paper is not enough to bring this
about, however; regular communication about the importance of compliance is part of this commitment.
It is important that the culture allows for open communication about compliance, and that employees are
encouraged to come forth promptly to discuss any problems with compliance.
Clause 4.4.2 of both standards is also relevant in this regard, since it sets requirements for creating
awareness about compliance with the environmental or OSH policy, by the organization’s employees as
well as third parties such as temporary workers.
Employee awareness and involvement can be encouraged by:
>
Oral and written communication from top management reiterating the importance of compliance,
and the progress made in this area.
>
Making this a regular agenda item in meetings.
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Identifying legislation and regulations
>
Identifying relevant
legislation and
regulations
§ 3.2
>
Keeping track of
changes in
legislation and
regulations
§ 3.2
>
Commitment to
compliance
§ 3.1
>
3.2
Sources:
– branch information
– competent authority
–www.antwoordvoorbedrijven.nl
– Agentschap NL
–www.arboportaal.nl
– consulting firm
Regular checking by
competent official
>
Impact of legal
requirements
§ 3.3
>
Which legislation and regulations are relevant
The organization must identify legislation and regulations that apply to it, meaning that they relate to
the organization’s environmental and/or OHS aspects. On the basis of the organization’s process steps/
operations/present facilities, an evaluation is made of which legislation and regulations may apply.
The requirements identified may be in both Dutch and European law or regulations. If an organization has
operations outside the Netherlands, it must also identify the applicable legal requirements for the other
country or countries. Identifying the relevant legislation and regulations is sometimes done in two steps.
Sometimes legislation and regulations only apply if a particular limit or threshold is exceeded, for example,
the presence of certain quantities of certain substances. It is then important:
>
to document why the legislation and regulations in question are applicable (or not);
>
in the case of ‘critical limits’, to ensure that limits are not exceeded, or if they are exceeded, that timely
action is taken.
A sample of this process is in annex 4.
For environmental legislation and regulations in the Netherlands, the organization can first ask:
>
Does the 2008 Activities Decree (Activiteitenbesluit) apply?
>
Does the organization need permits/licences to operate?
Connections to other legislation, semi-legislation (see below) and regulations arise from the Activities
Decree and Water Act.
If an organization needs permits or licences to operate, then using the requirements in the permit/licence
alone is not sufficient. The permit is a practical ‘translation’ of the law, in most cases of one particular law.
For example, the scope of a permit required under the Environmental Management Act will not go much
further than the Environmental Management Act itself, and may include a few requirements from
the Activities Decree. Other requirements that apply to the company are not covered by these permits.
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Regarding OHS legislation and regulations in the Netherlands, it is important to know if an approved
OHS ‘catalogue’ (regulations agreed by government and industry) is available for the sector in which the
organization operates.
At European level, there is a distinction between regulations, directives and decrees. Regulations apply
directly and do not have to be included in national legislation. Where European legislation is integrated in
Dutch legislation and regulations, it is sufficient to use only the Dutch legislation. Where this is not the case,
the European legislation applies in addition to the Dutch law.
Thus there are different levels of legislation, for example:
>
Permits/licences issued to the organization (if applicable).
>
National legislation.
>
European regulations, directives or decrees.
>
‘Semi-legislation’.
For the sake of convenience, in this publication ‘semi-legislation’ is understood to refer to all agreements
used as state of the art. Examples include:
>
Publications from the Hazardous Substances Publication Series (Publicatiereeks Gevaarlijke Stoffen,
for example PGS 15).
>
State-of-the-art descriptions such as laid down in the workbooks for the environment and industry policy
target groups or from the IPPC (Integrated Pollution Prevention and Control directive) in ‘best available
technology’ (BAT) and BREF (BAT reference) documents.
>
Covenants.
>
OHS ‘catalogues’ referred to above.
Besides the legal requirements, there are other requirements that must be identified. Examples of these are
requirements in insurance conditions, requirements of the parent company or requirements of customers.
These will not be discussed further in this publication, but they must be included in the management
system.
It must be realized that some legislation and regulations will be more clearly applicable and some less.
An organization must also have an intention to be familiar with, and to comply with, less obvious legislation
and regulations. The question is whether an organization can fairly be expected to be familiar with all the
applicable legislation and regulations. This will also be taken into consideration during the certification
process. The obvious legislation and regulations in any case will be those that SCCM has made summaries
of (see www.sccm.nl) and legislation and regulations related to activities considered to entail risk from an
environmental and/or OHS perspective.
Keeping up to date with legal and other requirements
The overview of legal requirements must be kept up to date, even when there are changes to legislation.
Organizations must therefore keep track of these changes and evaluate how they may affect areas such as
operational control, as well as measuring and monitoring and any objectives.
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Enshrined in a procedure (or another method in the system) are:
>
who keeps track of changes in legislation and regulations and other requirements;
>
what sources of information are used;
>
how often this is done;
>
who translates this information into requirements for the organization, and how;
>
how this is recorded;
>
how changes are communicated internally;
>
who determines how, and how often, compliance with the requirements is checked.
It is important that the person responsible for keeping track of and evaluating legislation and regulations
is also competent to do so (clause 4.4.2). Competence includes knowledge of:
>
the processes in the organization related to legislation and regulations;
>
the main thrust of the various kinds of legislation and regulations that can apply.
Often there are several officials/departments in an organization who play a part in this process, such as
HRM for health-related legislation, Technical Services for inspection requirements and relevant technical
standards, a QES (Dutch ‘KAM’; from quality, working conditions and environmental concerns) department
for general legal changes, and possibly a legal/accounting department for insurance conditions, etc.
Good working relationships and laying down who does what can make these things clearer.
With regard to keeping track of changes in legal requirements, there must also be a regular check to
see if the applicable requirements still fit the environmental and/or OHS aspects and the company’s
operations. New or different requirements may apply due to changes in, or of, operations. There may also be
requirements that no longer apply. If desired, evaluating the implications of legislation and regulations on
new operations or changes can be a part of an MoC (Management of Change) procedure.
The result
>
A procedure concisely laying down who identifies and keeps up to date with legislation and regulations
and how they do so (what the sources of information are; what format is used to record information;
frequency of updating; the person responsible; where information is laid down).
>
An overview of legislation and regulations in effect and any other particular requirements. Annexes 1
and 5 show examples of a format for identifying legislation and regulations, giving an indication of
the desired level of detail.
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E x am p l e
Annexes 1 and 5 give example of ways to set down information about the legislation and regulations.
It is not always immediately clear whether a specific law or regulation applies, for example when
its applicability is linked to concentrations of a substance. This can be laid down in an additional
document.
The Dutch guideline PGS 15, for example, contains many different requirements for storing hazardous
substances. A company must first use safety-data sheets to determine whether the substances and the
amounts it stores are governed by the PGS 15 guideline. These requirements are further dependent on
whether the substance is stored indoors our outdoors, in a closet, vault or rack, on the ground floor or a
higher floor. This information will determine if parts of the PGS 15 will (or will not) apply.
The organization must determine which specific prescriptions apply to be able to monitor compliance.
This is worked out with an example in annex 4.
3.3
Identifying relevant
legislation and
regulations
§ 3.2
>
Keeping track of
changes in
legislation and
regulations
§ 3.2
>
Impact of legal
requirements
§ 3.3
>
Implementing
measures ensuring
compliance
§ 3.4
>
>
>
Translating legal requirements into their impact on
the organization
Tasks and resposibilities in:
– job descriptions
– procedures and/or operational
instructions
– technical provisions
Once an organization knows which legislation and regulations affect it, it will be necessary to ‘unravel’ them
to find the specific requirements that affect it.
An organization can only make a pronouncement about its own compliance if these requirements are made
explicit. This is a time-consuming (albeit one-time) operation, especially for organizations subject to many
laws and regulations. Ultimately, however, it has great added value.
It must be clear how the legislation and regulations impact the organization, for example:
>
Technical provisions that must be made;
>
Organizational measures required;
>
Emissions that must be kept below certain levels;
>
Studies that must be done;
>
Notifications that must be made;
>
Obligatory monitoring, and monitoring reports.
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The applicable articles/requirements/rules for each legal or other requirement can be added to the overview
of legislation and regulations from step 1. Of course, this more detailed explanation may be set down in
another document within the management system.
Linking the legal aspects with the register of environmental and/or OHS aspects and the risk inventory will
make the right level of detail easier to see.
Linking legislation/regulations to activities and officers
Besides identifying legislation and regulations, an organization must identify and evaluate its
environmental and/or OHS aspects. The organization’s operations/processes will dictate the line of
approach. Making this identification usually shows a connection between the applicable legislation and
regulations and the officers responsible. The organization can opt to combine the translating all the legal
requirements into their impacts on the organization with the identifying of its environmental and/or OHS
aspects. If it does so, it is important to ensure that all legislation and regulations have been adequately
incorporated.
Ultimately, the responsibilities and tasks with regard to such things as legal requirements come together
in the job descriptions, procedures and/or operational instructions. When identifying both environmental
and/or OHS aspects and legislation and regulations, items in specific job or task descriptions or procedures/
operational instructions can be numbered and referred to (see 3.4).
The result
>
A procedure (whether or not combined with the procedure from 3.3) which lays down who is responsible
for determining the impact on the organization of the requirements in the applicable legislation and
regulations. Additional conditions for implementation (frequency, method of documentation, etc.)
can also be laid down.
>
An overview of the requirements per element of legislation and regulations, and their impacts on the
organization.
S am p l e
Annexes 2 and 6 contain tables with examples of how to systematically display the requirements in the
applicable legislation and regulations. Since a given requirement can apply to more than one area in
the organization, there is sometimes more than one ‘rule’ for the same requirement. Each table shows
the person or department responsible for compliance and for ensuring compliance, with reference to a
relevant document.
Another approach is to link the requirements directly to the tasks necessary for adequate compliance.
Examples are included in annexes 3 and 7.
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3.4
Ensuring that organizational and technical measures
for meeting the requirements are taken
>
Impact of legal
requirements
§ 3.3
>
Ensuring compliance
measures work
§ 3.4
>
Self-evaluation of
compliance with
legislation/regulations
§ 3.5
>
>
Implementing
measures ensuring
compliance
§ 3.4
>
>
Define action
in improvement
programme
to achieve
compliance
Methods for ensuring compliance include:
–checklist
– frequent measuring, recording and
reporting
– procedures and/or operational
instructions
– management of change procedure
– translating measures into action and
responsibilities
Once the organization knows which requirements apply, it determines how each requirement will impact it.
What measures and action are necessary to comply with the requirements?
If a requirement has not yet been met, an action must be defined in the organization’s environmental or
OHS programme (clause 4.3.3) to achieve compliance with it (this programme may be annually updated).
It may be necessary to notify and confer with the competent authority to define this action.
The next step is to ensure that these measures and actions are actually taken.
Doing so properly guarantees that the requirement is met even in between compliance checks (see step 4).
The method of ensuring compliance depends on the type of requirement for the organization. There are
roughly four types of requirements:
>
‘Static’ requirements: requirements for parts of the organization that do not change often, such as
requirements for a building (fire-proof doors, presence of a sprinkler system, etc.).
>
Technical requirements: requirements for technical measures and maintenance.
>
Performance and monitoring requirements: requirements that entail taking measurements (of
concentrations, annual obligations or amounts), keeping records or drawing up reports (including reports,
measurements and studies by third parties).
>
Organizational requirements: for matters such as training and instructing personnel.
The static requirements are checked once and ensured using such tools as a ‘management of change (MoC)
procedure’. This procedure determines, for example, what action and measures to take in the event of
certain changes.
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Other methods for guaranteeing compliance include:
>
a checklist which is gone through at defined intervals;
>
frequent measuring, recording and reporting (these can be kept up to date in a register or overview
of measurements, records and reports);
>
laying down the method in procedures or instructions which are ensured by means of internal audits;
>
translating requirements into action linked to officers and recording these actions once carried out
(see examples in annexes 3 and 7).
The severity of these measures is proportional to the risk of nonconformities. The degree of guarantee
must be heavier as the risks increase. The risk has often already been determined in the identification and
evaluation phase. Its place in a risk matrix (chance x effect) is useful here.
The management system can include an overview by element of how compliance was ensured, if desired
linked to the overview in step 2. If there are changes to legislation and regulations it will be easy to find
what parts of the management system must be adapted. This kind of overview is a convenient aid, but
the standard does not require it.
Result
>
Overview of how compliance with the requirements is ensured in the organization.
E x am p l e
Annexes 2 and 6 (right-hand columns) and 3 and 7 provide examples of how to ensure compliance with
the applicable rules. Annexes 3 and 7 provide partial examples of how the requirements are translated
into concrete tasks. Various instruments can be used including checklists, procedures, operational
instructions, and record-keeping).
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3.5
Implementing
measures ensuring
compliance
§ 3.4
>
Ensuring compliance
measures work
§ 3.4
>
Self-evaluation of
compliance with
legislation/regulations
§ 3.5
>
Internal audit
§ 3.6
>
>
Self-evaluation of compliance with legislation and regulations
Frequency of evaluation depending on, for example:
– number of legal requirements
– chance of nonconformities
– consequences of nonconformities for environment,
safety or working conditions
– frequency of change in requirements
– consequences of change in requirements
The essence of this element is that an organization must be able to say with conviction that it has its
compliance with legislation and regulations under control. It is difficult to guarantee that all legislation and
regulations are being complied with at every moment. Round-the-clock monitoring of all the requirements
is impossible. A focused approach should enable the organization’s management to have confidence
that there is a high level of compliance and that any nonconformities are resolved (where necessary, in
consultation with the competent authorities).
Assuming that the organization knows which legislation and regulations apply, and has translated
requirements they contain into their impacts on it, it can get a structural idea of its own compliance by
taking the following steps. This means that there is an established procedure for this self-evaluation.
Approach depends on the number of requirements
If the number of requirements in legislation and regulations is limited, a checklist can be used for a periodic
check that the requirements are being met. The management system can designate who fills out the
checklist and at what intervals, how the results are reported to management, and how the rectification of
nonconformities is ensured.
If the number of requirements is greater, it is a good idea to establish principles for the frequency with
which compliance with the individual requirements is evaluated. This frequency will depend on factors like
the chance of a nonconformity with the requirements and any consequences of a nonconformity. Using
these general principles as a basis, an organization can determine the appropriate frequency and method of
evaluation for each requirement.
Basis of the approach
To determine how and how often compliance with particular requirements should be evaluated, there must
be an idea of:
>
The chances of a nonconformity with these requirements arising.
>
The potential consequences of such a nonconformity for the environment, safety or working conditions.
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There is a relationship here with the requirement from the standard to identify and evaluate environmental
and/or OHS aspects. The OHSAS 18001 standard requires the application of a risk assessment in evaluating
the OHS aspects. The ISO 14001 standard does not require this, although organizations with an integrated
management system often do apply the risk assessment when identifying their environmental aspects. The
SCCM publication ‘Information for product organizations: identifying and evaluating environmental aspects’
provides examples. The outcome of the risk assessment can be used to determine how strictly to specify the
evaluation of compliance with legislation and regulation for a particular environmental aspect.
An organization can establish a few basic principles for specifying how it evaluates its own compliance.
This can be done using the matrix also used for the risk assessment, as shown in table 2. Each organization
can use its own categories for chances and effect.
Table 2: Example of principles for specifying self-evaluation of compliance
N at u re o f Stat i c
Techn i ca l
Requirement
Per f o rmance /
Or g an i z at i o na l
m o n i to r i n g
S co p e o f r i sk 1
Acceptable
Test only if a change or
>
maintenance check
>
2x per year data
>
1x per month on
incident occurs, as part of
2x per year
evaluated by
rounds with checklist
environment/OHS MoC2 procedure
coordinator
High-risk
1x per month on rounds
>
with checklist
check
monthly maintenance
>
4x per year data
>
4x per year records
evaluated by
evaluated by
environment/OHS
Extremely high
1x per week on rounds
>
with checklist
check
weekly maintenance
(unacceptable risk)
environment/OHS
coordinator
coordinator
>
12x per year data
>
12x per year data
evaluated by
evaluated by
environment/OHS
environment/OHS
coordinator
coordinator
1 Based on categories in table 6 of SCCM publication ‘Information for product organizations: identifying and evaluating environmental aspects ’
2 MoC = Management of Change procedure: among other things this procedure indicates what must be done, checked, recorded, etc. in the event of changes in the organization, processes or products.
The higher the risk becomes, the more often the self-evaluation must be performed. It must be clear how
compliance is evaluated for each requirement. This means that it is known:
>
Who is responsible for carrying out the evaluation;
>
What is evaluated (for example which rules or checklist, etc.);
>
How to record that the evaluation has been done, and how any nonconformities are dealt with.
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Evaluating compliance can take various forms, including:
>
as part(s) of a checklist used for routine checks;
>
periodic agenda point(s) during meetings;
>
continuous or periodic measuring programme(s) and reporting results;
>
incidental measurement;
>
specific evaluation by management/production manager etc.;
>
internal audits with an additional audit focused specifically on the process of identifying and complying
with legal requirements;
>
work-place inspections.
Checking compliance with legal and other requirements
According to the standard, the organization must periodically evaluate whether it is meeting these
requirements and must keep records of this evaluation. The frequency of this evaluation can differ for each
requirement. The organization must determine how often to evaluate the various requirements and how
to perform the evaluation.
The method and the frequency of checking, including tasks and responsibilities, are set down in the procedure.
Result
>
A procedure that sets out how the organization evaluates its own compliance.
>
An overview (periodically if desired) serving as a basis for determining during the management review
if compliance satisfies the principles established in the organization’s own policy.
3.6
Implementing
measures ensuring
compliance
§ 3.4
>
Ensuring compliance
measures work
§ 3.5
>
Internal audit
§ 3.6
>
Management review
of compliance
§ 3.7
>
>
>
Internal audit
Testing the effectiviness of procedures for
evaluation organization’s own compliance
During internal audits, the organization itself determines how the parts of its management system are
working. The question is also whether the management system is good enough to achieve its objectives.
One important objective is to comply with legislation and regulations. The internal audit yields essential
information for the management review (see 3.7). The SCCM publication ‘Internal audits’ contains
suggestions for carrying out internal audits.
Sometimes people think that the internal audits can be used to perform the ‘self-evaluation’ in section 3.5.
This is only possible to a limited degree. Since the internal audits are intended to evaluate the organization’s
own system, they also test the effectiveness of the procedures for self-evaluating compliance. Compliance
can only be evaluated using the internal audits if requirements from legislation and regulations are
embedded in procedures or instructions.
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3.7
Implementing
measures ensuring
compliance
§ 3.4
>
Ensuring compliance
measures work
§ 3.5
>
Internal audit
§ 3.6
>
Management review
of compliance
§ 3.7
>
>
Management review of compliance
Evaluation by management on
overview of compliance
performance
The results of the evaluation of compliance must be available during the management review (clause 4.6).
If management is to make a judgement of compliance, they must be given an overview of performance.
For top management, it is in any case important to know for which legislation and regulations compliance
is critical and/or insufficient and what measures need to be taken (if necessary) to improve compliance.
The cause of any nonconformity is also investigated so as to formulate corrective as well as preventive action.
An example of part of a management review procedure is in annex 9.
Result
>
A procedure for performing the management review (when, by whom, what information as input and
what decisions are made).
>
For each management review, a report of the evaluation by top management of (among other things)
compliance with legislation and regulations, and decisions about any necessary action (modifying policy;
making means available, etc.).
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chapter 4
Relationship to the other parts of
the management system
This publication discusses the parts of the ISO 14001 and OHSAS 18001 standards having a direct reference to
compliance with legislation and regulations. Other parts of the management system are also important for
proper compliance. A brief indication of their relationship to compliance follows, in order of the elements of
the standard.
The numbers of the sections of the standard are indicated, and are the same for both standards.
Identifying environmental and OHS aspects (4.3.1)
The legislation and regulations must be identified for the applicable environmental and/or OHS aspects.
For most companies, the relationship between the environmental and/or OHS aspects and the legislation
that applies to them is found in the register of environmental and/or OHS aspects. Often a column is added
with references to the applicable legislation and regulations.
This reference is useful in the event of changes in legislation, since it makes it easy to find the applicable
environmental or OHS aspect and the part of the organization to which it applies, and to assign the impact
of the new legislation to the right part of the organization.
This relationship goes both ways: if there are changes to an environmental or OHS aspect due to factors
such as changes in the process, the relevant legislation or regulation can be used to determine if the
requirements are still being met.
Competence, training and awareness (4.4.2)
The employee responsible for keeping track of legislation and regulations and translating the prevailing
requirements to their impacts on the organization must have sufficient knowledge to perform this task.
Communication (4.4.3)
Requirements in legislation and regulations that determine how work is performed must be communicated
to employees to achieve compliance.
Control of documents (4.4.5)
If procedures or instructions are drawn up for complying with and checking legislation and regulations,
they fall under the requirements for control of documents.
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Emergency preparedness and response (4.4.7)
One of the things that must be evaluated in the event of an emergency or disaster is its effect on compliance
with legislation and regulations and other requirements. If the requirements are not being met, even
temporarily, a decision must be taken whether to inform the competent authority. Action must also
be taken to control environmental and/or OHS aspects and reduce risks, and to come into compliance with
the legal and other requirements as quickly as possible again.
Monitoring and measuring (4.5.1) control of records (4.5.4)
Monitoring, measuring, or keeping records can be a requirement in prevailing legislation and regulations or
other requirements. It also records the demonstrability of compliance with legislation and regulations.
Nonconformity, corrective and preventive action (4.5.3)
If nonconformities are found during the evaluation of compliance, corrective and preventive action will be
taken as quickly as possible.
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annex 1
Sample simple register of legislation and
regulations for an offset printing firm
Law, re g u l at i o n o r ot her
R emarks
Way i n wh i ch l e g i s l at i o n , re g u l at i o n
re q u i remen t
o r ot her re q u i remen t s a p p ly
Activities Decree
Prevailing regulations determined using the
Applicable requirements are established / translated
Netherlands environment (VROM) ministry’s AIM tool; into a checklist. ‘Static’ (such as building-related)
see Activities Decree checklist. Not all of these rules
requirements are checked once. For recording, see file
actually apply. The rules that do not apply are in an
on checking legislation
overview indicating why each does not apply.
Handbook of environmental measures for
Last update 2009/2010.
The environmental measures checklist is gone
the graphics industry and packaging printers
through (once, see file on checking legislation).
All prescribed measures have been implemented.
Netherlands emission guidelines for air
VOC emission regulations for the graphic industry
The VOC requirements from the handbook are met
(NeR)
(general) from chapter 3.4.4. (April 2003).
(for recording, see file on checking legislation).
The measures regarding VOCs are in the workbook of
environmental measures and not in the NeR.
Decree on ozone-depleting substances
Applies to cooling installations maintained by
The company does not maintain cooling equipment
(October 2003) and Regulation on leak-tight
a company accredited by STEK (foundation for
itself. The STEK accreditation of the maintenance
cooling installations (1997)
preventing emissions in cooling technologies).
company is monitored by the suppliers’ evaluation.
Regulation on European waste catalogue
A company can use these lists to determine
All hazardous substances have EURAL codes and
(EURAL, 1 May 2002) and ‘ESV’ list
whether waste substances should be disposed of
waste substance numbers before they are disposed
(May 2004).
as hazardous waste or industrial waste, and if there
of. The codes are in the procedure for waste disposal,
are specific requirements for the use of substances.
and only change if the composition of a substance
The EURAL list is available through the environment
changes or if the company changes waste-collection
(VROM) ministry site, the ESV through the site
agency. Control of codes is ensured in the procedure
communications-industry organ KVGO. All wastes
for waste disposal.
disposed of as hazardous waste are identified in the
procedure for waste separation and disposal.
PGS 15 (2005, incl. errata pages)
The PGS applies to storage of hazardous substances
The overview of hazardous substances lists
if substances have an ADR code from the guidelines,
substances which fall under the PGS 15 rules, based
since the lower limit (from one of the ADR codes) is
on their ADR codes. The substances, quantities and
being exceeded.
storage location are used to determine which PGS 15
rules apply. These rules are translated into a PGS 15
checklist; see annex 4
(Dutch) Working Conditions Regulations
Requirements in Working Conditions Regulations
(article 4.3.2b) regarding maximum amounts article 4.3.2. For automatic dosing systems, the legal
of isopropyl alcohol (IPA) in damping water
limit is 8 percent by volume.
This requirement applies to all offset presses.
IPA concentrations are checked and recorded weekly.
The department head checks records and takes any
necessary action. Internally a limit of 5% is observed.
(2000).
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Law, re g u l at i o n o r ot her
R emarks
Way i n wh i ch l e g i s l at i o n , re g u l at i o n
re q u i remen t
o r ot her re q u i remen t s a p p ly
Regulation on packaging and packaging
The paper-fibre covenant III applied until 31 December
Paper and cardboard are disposed of separately.
waste – paper and cardboard covenant II,
2010 and the paper-fibre covenant IV applies from
The waste separating procedure regulates which
of which the paper covenant is a part.
1 January 2011 - 31 December 2014. The principle is to
grades are disposed of separately.
ensure collection of old paper and cardboard even if
paper prices are low. Separating different paper grades
will increase paper ‘yield’.
National Waste Management Plan (LAP2
Establishes which wastes must be separated.
2009)
The LAP2 indicates the minimum threshold quantities
above which wastes must be separated. There is not
a separate sector plan for printers giving additional
requirements. The separation rules are described in
the waste separation procedure.
REACH
The role identification tool on the Reach helpdesk site
The question tree from the identification tool and the
finds that the printer is a downstream user.
requirements for downstream users are laid down
in the ‘checking legislation’ file. The obligations for
downstream users are in the purchasing procedure.
Requirements regarding sustainable
This is not a legal requirement, but a customer
The requirements are in a table indicating how the
purchasing of printed matter
demand
requirements are being met.
The following (and other measures) do not apply:
1 Het Solvents Decree (VOC emissions guideline) does not apply to offset printers.
2 BREF: surface treatment with solvents (available through Infomil site but not applicable because
the company uses under 100 tons of solvents).
3 Packaging tax, applicable if over 50,000 kg of packaging is used per year. The company uses less than
this amount.
4 Insurance requirements; these have no relationship to environmental aspects.
5 The permit has been replaced by the Activities Decree as of 1 January 2010. There are no rules in
the permit which should be seen as custom guidelines during the transition period.
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annex 2
Sample applicable legal environmental
and compliance requirements
This example shows some of the requirements for a chemical company, along with the methods for
ensuring the requirement is being met.
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Wm**-1
Wm-2
S (Safety
General
Safety
S-2
S-3
S-4
S-5
S-6
S -7
S -8
B-1
W-1
W-2
W-3
D-1
Building
Waste
Discharge
Act) -1
N o.
S u b j ec t
Water act
accredited collector/processor.
waste
permit art. 4.1
per 24 hrs, sampling 1x per quarter.
Pollution of Surface Waters Act Maximum discharge of Cr, Cu, Zn is 2 mg/l, flow rate max 4.5 m3
Waste containing oil must be separately removed and taken to an
Sector plan oil-containing
rubble created.
Separate disposal of wastes: plastic cups (500 or more p/wk),
chapter 15
(LAP2)
Separate disposal of paper/ /plastic/pallets/chemicals.
Fire extinguishers, annual inspection by expert.
coupling and uncoupling of the hose.
truck must be present during the entire filling process, including
tank from a tank truck, the connection between tank and tank
Measures must be taken against static electricity while filling a
uncoupling the filling hose and while filling a tank.
motor of a tank truck must be turned off while coupling and
Open fires and smoking are prohibited while filling a tank. The
Production
Tech. services
All departments
Production
Tech. services
Production
Production
Analysis
Checklist
instructions
Operational
instructions
Operational
Maintenance list
Procedure
Procedure
capacities
with max. storage
Overview of
Storehouse
storage above the drip tray).
Checklist
Storehouse
storehouse set-up
wood (40 kg or more p/wk), metal (40 kg or more p/wk), and any
LAP2
Certificate +
Recording system
Checklist
Storehouse
Checklist*
Checklist
Report
Maintenance list
Method
Storehouse 2
Storehouse 1
Storehouse
KAM (QES) dept.
Technical services
Pr o cess/ de p t.
(minimum 110% of the largest package and at least 10% of the total
Product storage capacity: leak-proof basins for all stored products
Gas bottles must always be secured.
person.
proof floors must be inspected once every 5 years by an authorized
The quality of the floor must be visually assessed annually. Liquid-
Maximum of 50 kg spray cans.
Maximum of 50 kg spray cans.
(otherwise a journal must be kept).
Quantity of hazardous substance not more than 2500 kg/litre
submitted to competent authority by 1 March at the latest.
Annual progress report about 4-year environmental plan,
Annual inspection of earthing installation by an accredited expert.
R e q u i remen t
Art. 16
Wm article T-12
Wm article T-11
paragraph 3.9
paragraph 6.2
paragraph 3.3
paragraph 3.1
paragraph 3.1
paragraph 3.18
Wm article I-9
Wm article I-14
A rt. n o,
mgmt plan 2
National waste
Covenant
Buildings decree
Wm
Wm
PGS 15
PGS 15
PGS 15
PGS 15
PGS 15
PGS 15
Wm
Wm
Law
CL 101
WI 101
WI 101
CL 57
Cl 56
CL 56+57
D o c . n o.
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D-2
D-3
E-1
Emissions
Arbobesluit
Arbobesluit
Arbobesluit
A-5
A-6
A-7
* See example in annex 4
**Wm: Environmental Management Act
Arbobesluit
A-4
(‘Arbobesluit’)
Conditions Decree
Working
(‘Arbowet’)
Conditions Act
Working
A-3
A-1
OHS
Permit
Permit
Arbowet
E-3
Permit
Water act
Water act
Law
A-2
E-2
to air
N o.
S u b j ec t
R e q u i remen t
quarter.
Article 8.3
Article 8.2
Article 8.1
Article 4.3
Article 4.2
KAM/QES and Tech.
services
maintained and repaired.
KAM/QES.
the RI&E.
Personal protective equipment must be available, used,
Personnel and
KAM/QES.
correctly.
The use of personal protective equipment must be evaluated in
Purchasing and
department
Personal protective equipment must meet standards and be used
Personnel
values.
department
Exposure to hazardous substances must remain below threshold
Personnel
substances.
department
and reported.
An additional RI&E must be done for exposure to hazardous
Personnel
Workplace accidents and occupational illnesses must be recorded
department
and Action Plan.
Article 9
Personnel
Employer must draw up a Risk Identification and Evaluation (RI&E)
Article 5
Production
Production
Purchasing
Production
Annual measurements according to set-up measuring plan.
Investigate decreasing emission of hydrocarbons from the facility.
Draw up a solvents ‘accounting system’.
results of analyses, and quantity of wastewater per 24 hrs.
Production
Pr o cess/ de p t.
Wm article L-7
Wm article L-6
Wm article L-5
permit 6.1 and 6.2
Pollution of Surface Waters Act An environmental log must be kept containing sampling data and
permit art. 4.2
Pollution of Surface Waters Act Discharge of mineral oil maximum 20 mg/l, sampling 1x per
A rt. n o,
management
Procedures, supply
RI&E and report
guide
information, safety
Procedure,
records, procedure
measurements ,
Overview of
Procedure, RI&E
plan
Emergency response
Procedure and
Procedure, RI&E
Recording system
Report
Recording system
Recording system
Analysis
Method
D o c . n o.
annex 3
Sample translation of legal
environmental requirements into
concrete tasks
Below is an example of a company that has translated its legal requirements into employee tasks
(only those involving storage of hazardous substances are shown here). Where possible, the company has
integrated the requirements into the procedures and operational instructions in its management system.
For monitoring purposes (and sometimes for performing the tasks) the tasks have been put in a computerized
system. After a task is completed, it must be ‘cancelled’ in the system. The environmental-OHS coordinator
does random checks to see if the tasks have been performed well and carefully, and if compliance is being
ensured and/or checked by means of the formulated tasks.
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PGS
S u b j ec t
PGS 15
re g u l at i o n
Law o r
D e ta i l ed
(primarily partitioning).
Check whether personnel are
etc.
>
participants’
>
table 3 is based on the
transportation legislation
ADR. The table shows the
lower limits of hazardous
substances. The PGS 15 does
not apply under this limit.
Chapter 3 (General) applies
to [company name] for
both internal and external
storage facilities, and
chapter 6 (Storage of gas
bottles) sets requirements
for storage of gas bottles
over the limit of 115 litres.
hazardous
substances
substances in such a way
as to achieve an acceptable
level of protection for people
and the environment. The
required level of protection
is determined by the current
state of the art for constructing
storage facilities, fire-fighting
systems and work equipment.
The categories and definition
of hazardous substances in
PGS 15 are also used in the
Carriage of Dangerous Goods
Act. Classification of hazardous
permit for storage site and
additional requirements
from PGS 15
conformance with the European
ADR agreement.
in the environmental
>
substances takes place in
checklist of requirements
informed
which employees must be
involving subjects about
reports of consultations
information sessions
and records of
informative materials
storage sites, partitioning,
maximum quantities,
specified
the ADR safety advisor are
Check that the activities of
substances
about storing hazardous
the requirements agreements
Inform new employees about
storage sites’
the checklist ‘requirements for
permit requirements, using
satisfy the environmental
Check that the storage sites
‘overview of partitions’.
using the ‘PGS 15 checklist’ and
stored according to the rules,
hazardous substances are
Check whether packaged
adequately trained.
storing hazardous substances
and agreements about
informed of requirements
performing tasks are
hazardous substances in
substances containing
>
The classification of
Check whether personnel
Task descr i p t i o n
packaged
overview of hazardous
R e f erence
Storage of
re q u i remen t s
descr i p t i o n o f
storing packaged hazardous
L i nk
The guideline contains rules for
S u mmary
monthly
annually
quarterly
annually
Fre q u ency
….
….
….
….
h o l der
Task
annex 4
Sample translation of general
environmental requirements into
specific rules
PGS 15 is a guideline with many different requirements for storing hazardous substances. Using safety-data
sheets, a company must first determine whether the substances and amounts of them stored fall under PGS
15. The requirements are then dependent on whether the substance is stored inside or outside, in a closet,
vault or rack, on the ground floor or an upper floor. These findings will determine which parts of the PGS 15
will (or will not) apply. To monitor compliance, it must be determined which specific rules apply.
The substance of this annex will be linked to the overview of the applicable legislation and regulations in
annex 1 and/or the elaboration of the requirements in annex 2. One of the rules the company must obey
is the PGS 15 for storing hazardous substances. The PGS 15 analysis is based on the overview of hazardous
substances and ADR codes that a company must have available.
Analysis of the applicable requirements from PGS 15 (28 June 2005) including published addenda sheets up
to 1 September 2010
(Note: this overview is not complete!)
§ 3.1
Indicates that chapter 7 of PGS 15 (§ 3.11) should be referred to for storage of spray cans. It also indicates
that the threshold is 50 kg. This means than the PGS 15 only applies if more than 50 kg of spray cans are
stored (§ 3.1.2).
Conclusion: the company stores less than 50 kg of spray cans, thus PGS does not apply here.
Working stock (the amount used in one day or batch) is not covered by PGS 15.
Drawing off or racking is not permitted in the storage space.
Empty packaging not yet cleaned is covered by PGS, however, and is stored as full packaging.
§ 3.2
Construction requirements
Conclusion: the requirements for the hazardous substances storage space are covered by the prevailing
requirements since the storage space existed before the publication of PGS 15 in July 2005.
The requirements for storage space are listed in the permit. These requirements are checked once only,
and compliance is further guaranteed by means of a management of change (MoC) procedure.
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§ 3.3
Concerns floor quality
Conclusion: the floor has a liquid-proof finish and must undergo periodic visual inspection.
§ 3.4
Concerns the quality of racks
Conclusion: construction requirements are checked and ensured in the management of change
procedure. They have periodic visual inspection.
§ 3.5Protection from lightning
Conclusion: lightning-proofing the facility is not necessary. This is determined using the Dutch standard
NEN 1014. See the company notice: Implementing the calculation model for lightning-proofing.
§ 3.6 Explosive safety
Conclusion: given the nature of the substances, there is no danger of explosion and therefore no
measures of this type need to be taken.
§ 3.7
Ventilation
Conclusion: the requirements for ventilation in the storage space were introduced during construction
of the space. At least once a year, the ventilation equipment is checked to see that it functions properly
and that nothing is blocking it. When the check has been performed it is recorded in the checklist
‘Meeting the PGS 15 requirements’.
§ 3.8Prevention of contaminated rainwater
Conclusion: this rule does not apply, since the external storage is in an appropriate (closed) container.
Rainwater cannot get onto the floor of the container.
§ 3.9Product containment
Conclusion: All stored containers have leak-proof basins underneath. These basins must be able to
contain at least 110% of the contents of the largest package and with at least 10% of the total amount
stored. We will check this periodically.
§ 3.10Fire-proof storage closets
Conclusion: Since the company uses storage vaults and not closets, this rule does not apply.
§ 3.11Packaging and labelling
The packaging of hazardous substances meets the ADR requirements. The substances are stored in the
approved packages in which they were delivered. The same holds for the labelling of the hazardous
substances, which were labelled by the supplier.
Conclusion: Only undamaged, labelled packages are being stored. If labels are (or have become)
illegible, a replacement label is attached. The legibility of labels and damage to packages is checked.
NB: If a company has several storage spaces which all are covered by PGS 15, the applicable rules for
each space must be determined. The rules can differ on the basis of, for instance, location (inside vs.
outside, ground floor vs. upper floor), kind of substance stored or the amount(s) of substances stored.
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Sample PGS 15 checklist (not complete)
A rt. N o.
R u l e / q u est i o n f r o m PG S 15
C heck y es/ n o
Alg.
Are all substances (including wastes), excepting the working stocks stored in the
R emarks / f i nd i n g s
closets or basins intended for them?
Alg.
Does everything look tidy and orderly (good housekeeping)?
3.1.3
Is the working stock no more than one day’s consumption?
3.1.4
Are there indications that draining or racking is taking place in the storage area?
3.1.5
Are empty, not-cleaned packages stored like full ones?
3.3.3
Is the floor clean and without cracks? (Visual inspection)
3.4
Is the quality of closets, basins, and racks good? (No damage, collapsed shelves, and
collision protection still intact)
3.9
Are the leak-proof basins large enough? (each basin must be able to accommodate
110% of the volume of the largest container and at least 10% of the total volume
of packages stored), calculated for each basin separately. If the agreements
for substances and number of containers per basin/rack are met, the volume
requirement has been met.
3.11
Is the packaging of the hazardous substances sufficient? (whole, sealed, original, ..)
3.11
Does the packaging have proper labelling and hazard symbols?
Check that substances which should not be stored together are stored separately).
See the partitioning overview ……
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annex 5
Sample of simple register of
OHS legislation and regulations for
an offset printing company
Law, re g u l at i o n o r
R emarks
Way i n wh i ch l e g i s l at i o n , re g u l at i o n o f
ot her re q u i remen t
ot her re q u i remen t s a p p ly
Working Conditions Act
The Working Conditions Act contains general rules for
Using the risk inventory and evaluation for the
(Arbowet)
employers and employees, to ensure a safe and healthy
‘Grafimedia’ sector, the company checks to see that
workplace. Not every article in the Act applies to this company.
it is complying with all the rules from the Working
The articles which do not apply are in an overview indicating
Conditions Act, Working Conditions Decree and the
why each does not apply.
Working Conditions Regulations. This RI&E is performed
every four years, and must be done sooner if there are
changes to legislation and regulations or in the company.
There is an annual check to see if the RI&E must be
repeated earlier.
Working Conditions Decree
The general rules in the Working Conditions Act are elaborated
(Arbobesluit)
on in the Working Conditions Decree. Here as well, not all
See text for Working Conditions Act.
articles will apply. The articles that do not apply are in an
overview indicating why each does not apply.
Working Conditions Regulations
The Working Conditions Regulations contains more specific
(Arboregeling)
rules of the Working Conditions Act. Not all regulations apply to
See text for Working Conditions Act.
this company. The articles that do not apply are in an overview
indicating why each does not apply.
Graphic media sector
The Grafimedia requirements ‘catalogue’ was drawn up by
The company has read all the subject pages of the
requirements
representatives of both employers and employees in the
‘catalogue’ on www.arbografimedia.nl. Using the
(‘Arbocatalogus Grafimedia’)
graphic media branch. It contains minimum standards that
checklists and the RI&E, they have checked if all
companies working in the branch must meet, as well as
requirements are being met. There is a check each year
suggestions for solutions.
of whether there have been any changes that make it
necessary to read the pages again.
Working Times Act
The Working Times Act prohibits employees working too many
The Ministry of Social Affairs’ (SZW) brochure on the
(Arbeidstijdenwet)
hours in a day or week.
Working Times Act has been read. The working hours
and break times meet the requirements in the Act. If
working hours or break times change, or if an employee
is pregnant, the brochure will be checked again. There is
an annual check to see if there have been changes to the
Working Times Act.
Work and Care Act
The Work and Care Act regulates different forms of leave,
If an employee’s leave may fall under the Work and
(Wet Arbeid en Zorg)
so that employees can better coordinate work with receiving
Care Act (pregnancy, maternity, adoption, foster care,
and giving needed care.
emergency and other short-term leave, care leave,
maternity/paternity leave, or long-term care under the
Dutch life-course savings scheme), the checklist based
on this law is used.
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Law, re g u l at i o n o r
R emarks
Way i n wh i ch l e g i s l at i o n , re g u l at i o n o f
ot her re q u i remen t
ot her re q u i remen t s a p p ly
Gatekeeper Improvement Act
Officially called the ‘Eligibility for Permanent Invalidity Benefit
In the event of illness, the company goes through the
(Wet verbetering Poortwachter)
(Restrictions) Act,’ this Act provides rules for the first two years
checklist, drawn up in consultation with the company
of illness, with the goal of keeping the period of illness as short
doctor.
as possible.
Tobacco Act (Tabakswet)
The Tobacco Act provides measures to minimize tobacco use,
There is no smoking allowed inside the company
and to protect non-smokers from second-hand smoke.
premises. Smokers may smoke in the smoking area
outside the building. This complies with the Tobacco Act.
Each year there is a check for changes in the Tobacco Act.
Works Councils Act (Wet op de
This Act contains rules for the works councils and employee
Since the company has fewer than 50 employees, it is
Ondernemingsraden)
representative bodies.
not required to have a works council. An annual poll is
taken among employees asking if they find a need for an
employee representative body.
Grafimedia Collective Labour
The Collective Labour Agreement for the Grafimedia sector
The agreements in the CAO are incorporated in the
Agreement (CAO)
contains agreements about illness, leave, risk inventory and
checklist for leave and the checklist for illness. A
evaluation, and training.
summary is made of agreements about training that is
used in performance appraisal interviews. In performing
the RI&E, the testing agreements described in the CAO
are used. With any new CAO, the checklists are modified
and there is a check to see if other modifications to policy
of procedures are necessary.
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annex 6
Sample applicable legal
OHS requirements and how to ensure
compliance
S u b j ec t
N o.
Law
A rt. N o.
R e q u i remen t
Pr o cess/ D e p t.
E ns u red by
Policy
P-1
Working Conditions
Article 5
The employer must draw up a risk
Personnel and QES
Procedure, RI&E
identification and evaluation (RI&E) and
depts.
Act
D o c . n o.
an action plan.
P-2
Working Conditions
Article 9
Act
Occupational accidents and illnesses
Personnel and QES
Procedure,
must be recorded and in certain cases
depts.
Emergency plan
An additional RI&E must be made for
Personnel and QES
Procedure, RI&E
exposure to hazardous substances.
depts.
Exposure to hazardous substances must
Personnel and QES
Overview of
stay below threshold limit values.
depts.
measurements,
reported.
P-3
Working Conditions
Article 4.2
Decree
P-4
Working Conditions
Article 4.3
Decree
records,
procedure
Personal
PPE -1
Working Conditions
Article 8.1
Decree
Protective
Personal protective equipment
Purchasing and
Procedure,
must meet standards, fit the hazard,
QES depts.
informing
Equipment
circumstances and the person, and be
employees,
(PPE)
used correctly.
safety guide, PPE
register
PPE -2
Working Conditions
Article 8.2
Decree
PPE -3
Working Conditions
Article 8.3
Decree
The use of personal protective
Personnel and QES
equipment is evaluated in the RI&E.
depts.
Personal protective equipment must be
Purchasing, QES
available, used, maintained and repaired. dept. and technical
services
RI&E report
Procedures,
supply
management,
PPE register
Noise
N-1
Working Conditions
Article 6.7
Decree
The RI&E must evaluate the noise levels
Personnel and QES
Procedure, RI&E
to which employees are exposed.
depts.
report, Noise
reports
N-2
N-3
Working Conditions
Articles 6.8
If threshold limit values are exceeded,
Technical services,
RI&E report, noise
Decree
and 6.9
measures are taken, keeping in mind
Personnel and QES
report, action
occupational hygiene requirements.
depts.
plan
An audiometric examination must be
Personnel and QES
Procedure,
offered if threshold limit values are
depts., company
register,
exceeded.
physician
individual
Working Conditions
Article 6.10
Decree
medical dossiers
N-4
Working Conditions
Decree
Article 6.11
Information and instructions should be
Personnel and QES
Procedure,
given to employees if certain threshold
depts.
RI&E-report,
limit values are being exceeded.
noise reports,
information
campaign
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S u b j ec t
N o.
N-5
N-6
Law
A rt. N o.
R e q u i remen t
Pr o cess/ D e p t.
E ns u red by
D o c . n o.
(Rubber/plastics
Solutions
Compressed-air hose openings must be
Technical services
Checklist,
CL 201
industry)
for noise
fitted with “quiet” nozzles. Employees
and QES dept.
information
Requirements
are given instructions (they usually
(Arbocatalogus
believe that these nozzles work less
NRK)
well).
NRK Requirements
Solutions
Use mufflers when releasing product
for noise
(releasing compressed air after pressure
campaign
Technical services
Checklist
Redesign
CL 201
buildup).
N-7
N-8
NRK Requirements
NRK Requirements
Solutions
Cool with water instead of quick air-
R&D, Technical
for noise
cooling.
services
Solutions
Cleaning with a vacuum cleaner instead
Production
for noise
of compressed air.
Procedure,
information
campaign
N-9
NRK Requirements
Solutions
Limiting how far a product may fall.
for noise
N-10
NRK Requirements
Solutions
and breaks
Working Times Act
Article 5:7
-1
Article 5:7
Article 5:7
Redesign
services
Breaking the fall of dropped products.
for noise
Working hours WRT
R&D, Technical
R&D, Technical
Redesign
services
An employee may work no more than 12
Personnel dept.
Registration
hours per shift.
and production
system
An employee may work no more than 60 Personnel dept.
Registration
hours per week.
and production
system
The average weekly hours worked over
Personnel dept.
Registration
a period of 4 weeks must not exceed 55
and production
system
The average weekly hours worked over
Personnel dept.
Registration
a period of 16 weeks must not exceed
and production
system
If an employee works more than 5.5
Personnel dept.
Registration
hours, he or she must have at least 30
and production
system
If an employee works more than 10
Personnel dept.
Registration
hours, the break must be at least 45
and production
system
hours.
Article 5:7
48 hours.
Article 5:4
minutes’ break. This may be split into
two 15-minute breaks.
Article 5:4
minutes. It may be divided into several
breaks of at least 15 minutes each.
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annex 7
Sample translation of legal
OHS requirements into concrete tasks
Below is an example of a company that has translated its legal requirements into employee tasks
(only a few tasks related to noise). Wherever possible, the company has integrated the requirements into
the procedures and operational instructions in its management system. For monitoring purposes
(and sometimes for performing the tasks) the tasks have been put in a computerized system. After a task
has been completed it must be ‘cancelled’ in the system. The environmental-OHS coordinator performs
random checks to see if the tasks have been performed well and carefully and if compliance is being
ensured and/or checked by means of the formulated tasks.
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tools
machines/equipment/tools. Once
a year, check that all equipment is
included in the plan.
employees on the work floor,
technical services employees, and
themselves can provide variety in
their job description.
outside companies.
Once. At acquisition of new
Having employees do more
maintenance is performed by
for each machine.
Make a maintenance ‘passport’
Lay down what part of
maintenance ‘passport’
maintenance ‘passport’
preventive maintenance
‘passport’ for each machine.
If desired, make a maintenance
included in the plan.
a year, check that all equipment is
planned in advance.
of machines,
equipment and
machines/equipment/tools. Once
Once. At acquisition of new
drawn up in which review days are
maintenance
Draw up a maintenance plan.
A maintenance plan must be
Preventive
Maintenance plan
necessary.
do so.
Once. At acquisition of new
the equipment, see if inspection is machines/equipment/tools.
On the basis of instructions for
circumstances are a reason to
Equipment is inspected if special
Logbook and maintenance plan
necessary.
tested.
be inspected and if necessary
inspected/tested.
Once. At acquisition of new
the equipment, see if inspection is machines/equipment/tools.
Worn equipment which could
Conditions Decree.
date and complete.
year, check that everything is up to
Conditions Decree
requirements from the Working
On the basis of instructions for
equipment is acquired. Once a
requirements from the Working
equipment complies with the
Logbook and maintenance plan
Supplement when new
CE marks complies with the
cause dangerous situations must
www.wetten.nl
Once for all equipment.
See if equipment without
If the above is not the case, it
must be demonstrated that the
relevant Commodities Act decrees.
be periodically
Equipment must
it may be assumed that the
decrees.
Equipment report
date and complete.
accordance with the instructions,
Commodities Act
equipment complies with the
year, check that everything is up to
Dutch-language instructions.
of conformity and is used in
with the relevant
equipment is acquired. Once a
make a set with the EC declaration Supplement when new
of conformity and instructions.
For every item of equipment,
declaration of conformity and
Once for all equipment.
Fre q u ency
Overview of equipment with EC
D escr i p t i o n o f task
mark, has an EC declaration
R e f erence
If work equipment has a CE
www.wetten.nl
Work equipment
re q u i remen t s
D e ta i l ed descr i p t i o n o f
must comply
L i nk
S u mmary
…..
…..
…..
…..
…..
…..
…..
by
p er f o rmed
Task
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L i nk
cutter
working with a
vlees.nl
Guidelines for safe www.arbocatalogus-
S u mmary
cutters. Give new employees
information about safety when
working with cutters.
safe use of the cutter (proper use
of safety hood/catch, necessary
caution when removing meat).
meetings to working safely with
Devote time in the employee
Training period form.
6. Employees working with cutters Minutes of employee meeting.
receive repeated instruction in
blades, and supervise their use.
employees who replace cutter
register.
blades.
Provide cut-resistant gloves to
Personal protective equipment
machine annually.
Check the condition of the
gloves when replacing the cutter
Maintenance schedule
5. Employees wear cut-resistant
condition.
4. The machine is in good
requirement is still being met.
periodic maintenance, check if this
purchasing the cutter. During
schedule.
cutter does not work if there is a
malfunction in the safety control.
Check these aspects when
Logbook and maintenance
requirement is still being met.
periodic maintenance, check if this
3. There is a feature where the
accidentally.
purchasing the cutter. During
schedule.
such that it cannot be turned on
requirement is still being met.
Check these aspects when
Logbook and maintenance
2. The cutter‘s operating system is
periodic maintenance, check if this
safety catch.
purchasing the cutter. During
schedule.
the hood is raised. The hood has a
Check these aspects when
Logbook and maintenance
D escr i p t i o n o f task
ensures that the machine is off if
R e f erence
1. The cutter has a hood that
safety requirements:
The cutter meets the following
re q u i remen t s
D e ta i l ed descr i p t i o n o f
Annually and at hire.
Continuous
Annually.
At purchase and annually.
At purchase and annually.
At purchase and annually.
Fre q u ency
…..
…..
…..
…..
…..
…..
by
p er f o rmed
Task
annex 8
Sample translation of general
OHS requirements to specific rules
This is an example of a way to determine whether legislation and regulations apply using specific rules.
Sometimes legislation and regulations only apply if certain limits are exceeded. Here, a company canteen
has computer display units (VDUs) in several places. They must find out which work stations the OHS
legislation and regulations about working with computer displays apply to.
Article 5.8 of the Working Conditions Decree indicates that the articles about working with computer
displays do not apply to:
1a
Operating stations on machines;
1b Computer systems intended primarily for use by the public;
1c
So-called portable systems not continuously in use on a workstation;
1d Calculating machines, cash tills and other equipment provided with a small display for information
or quantities and required for the direct use of this equipment;
1e
Conventional typewriters with displays;
2
Neither does this Section apply to work whereby an employee usually uses a VDU less than
two hours in every 24 hours.
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Below is a list of the displays in the company canteen and in its offices, work spaces and storage spaces.
S pace
D escr i p t i o n o f d i s p l ay
n u mber
D o es O H S
E x p l anat i o n
C heck i n g
l e g i s l at i o n
a p p ly ?
1.01
Restaurant team leader’s display
Yes
More than two hours per day, traditional
computer work station.
1.01
Cook’s display
No
Average of 1.5 hours per day.
Check annually if amount of
computer work has increased.
1.02
Assistant team leader’s display
No
Average of less than one hour per day.
1.02
Kitchen workers’ shared work station
No
Average of less than one hour per day.
1.03
Cold room, display on refrigerator
No
Display for direct use of equipment (1d).
1.04
Walk-in freezer room, display on freezer
No
Display for direct use of equipment (1d).
1.10
Restaurant, staffed cash desk
No
Cash till (1d)
1.10
Restaurant, automatic cash desk
No
Used by the public (1b)
1.10
Restaurant, computer for ordering
No
Average of less than one hour per day.
1.12
Dishwashing area, display on dishwasher
No
Display for direct use of equipment (1d).
1.13
Kitchen, deep-fat fryer display
No
Display for direct use of equipment (1d).
1.13
Kitchen, oven display
No
Display for direct use of equipment (1d).
1.15
Supply room, PDA for supply management
No
Portable system not continually in use (1c).
Check annually if amount of
computer work has increased.
Check annually if amount of
computer work has increased.
Check annually if amount of
computer work has increased.
Conclusion
For the time being, the rules from OHS legislation and regulations relevant to computer display work only
apply to the restaurant team leader’s work station.
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annex 9
Sample management review procedure
Below is a part of the management review procedure, around the input and analysis regarding legislation
and regulations.
Documents to be supplied for the management review:
>
procedure for keeping track of legislation and regulations;
>
overview of changes in the organization (including other changes in process or product) and the follow-up
with regard to legislation and regulations (including updating applicable legislation and regulations
fitting the environmental and OHS aspects, determining impact on the organization, taking measures to
achieve compliance, information campaigns within the organization, etc.);
>
report of evaluation(s) of compliance with legislation and regulations (performance): conclusions,
nonconformities, analysis of cause, corrective or preventive action;
>
reports of external monitoring (by government authorities etc.): nonconformities, cause analysis,
corrective or preventive action;
>
reports/results of internal and external audits regarding legislation and regulations: nonconformities,
cause analysis, corrective or preventive action;
>
results of competency analysis of employee(s) responsible.
Analysis by top management:
>
evaluate whether the method of keeping track of legislation and regulations ensures an up-to-date
register of legislation;
>
evaluate whether changes in the organization have been adequately followed up;
>
evaluate if the way compliance is achieved, and the compliance itself, is sufficient;
>
evaluate whether sufficient corrective or preventive action has been taken;
>
evaluate whether the procedure for corrective action is sufficient;
>
evaluate whether the employee(s) involved have sufficient competence and if they need additional
training.
Conclusion by management:
With the management review, top management determines if the management system is still suitable,
appropriate and effective. Part of this is determining if the compliance management system or method
is still suitable, appropriate and effective, and that it ensures continual compliance with legal and other
requirements.
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Contact
Please do not hesitate to contact us if you have any questions. We will
gladly help companies, organizations, consultants, supervisory bodies,
certification bodies and other stakeholders.
SCCM
P.O. Box 13507
2501 EM The Hague
T +31 (0)70 362 39 81
E info@sccm.nl
I www.sccm.nl
Publication SCCM, Den Haag
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