2ndInternal Audit
of the United Nations University
Tokyo, Japan
February 7, 2002
Prepared by
UNU Internal Audit Team
Hiroshi Sasaki (UNU/HQ) - Lead auditor
Makiko Yashiro (UNU/GEIC)
Brendan Barrett (UNU/IAS)
Nobuyuki Kawade (UNU/IAS)
Report Ref: UNURep070202
Assessment / Internal AuditLocation / United Nations University Centre, Global Environment Information Centre, UNU/Institute of Advanced Studies
Address at which the assessment took place / 53-70, Jingumae 5–chome, Shibuya-ku, Tokyo 150-8925, Japan
EMS Coordinator / Professor Motoyuki Suzuki, United Nations University, Tokyo, Japan
Lead Auditor / Hiroshi Sasaki (UNU/HQ)
Date / 7th February 2002
ISO14001 Internal Audit TeamThe United Nations University – Page 1
ISO 14001 Internal AuditInternal Audit Team and Function / Name / Function
Ms. Makiko Yashiro
Mr. Nobuyuki Kawade
Mr. Brendan Barrett
Mr. Hiroshi Sasaki / Auditor (January 31st 2002)
Auditor (January 31st and 4th February 2002)
Auditor (January 31st and 4th February 2002
Lead Auditor (January 31st and 4th February 2002)
Internal Audit Period / January 31st and February 4th, 2002
Internal Audit
Names and functions of principle persons interviewed / Name / Function
Mr. Yuji Oshige
Mr. Max Bond
Mr. Takemura
Mr. Peter Button
Mr. John B. Datsomor
Ms. Mayako Matsuki
Mr. Yuhei Sakurada
Mr. Libor Jansky, Ph.D.
Prof. A.H. Zakri
Ms. Izumi Ono
Mr. Ng Chong
Prof. Motoyuki Suzuki
Mr. Odagawa
Mr. Kawamura / Sr. Procurement Assistant, UNU Administration (Unit 4), ISO14001 Steering Group Member
Office of the Rector, UNU Centre (Unit 2), Acting Director of Administration, Headquarters UNU Administration (Unit 4)
Sanko Ltd, UNU Administration (Unit 4)
Personnel Office, UNU Administration (Unit 4)
Online Dissemination, UNU Administration (Unit 3)
Library, UNU Services (Unit 3)
Finance Officer, UNU Administration (Unit 4)
Senior Academic Programme Officer, UNU Centre (Unit 2)
Director, IAS/UNU (Unit 1)
Research Assistant, GEIC, (Unit 2))
Chief IT Officer, UNU Services (Unit 3)
Vice Rector, EMS Coordinator (Unit 2)
Biru Daiko, UNU/IAS (Unit 1)
GEIC (Unit 2)
Summary of most important observations, positive and negative regarding implementation and effectiveness of the EMS. / Sframework for an Environmental Management System under ISO 14001 has been established at the UNU from May 1999 onwards. The University was certified on 26 January 2001.
This internal audit involved interviews with fourteen representatives from the UNU and its subcontractors based at the Tokyo campus. The auditors found the levels of environmental awareness of the intervieweesto be high. Moreover, interviews with senior management at the UNU clearly showed strong support for the ISO14001 Initiative. The UNU environmental policy is understood by all interviewed and respondents showed a keen awareness of some of the main environmental issues facing the university. At the time of implementing this internal audit, the environmental review for the UNU had not been completed. This is because the university works on a biennium basis and data for the period to December 2002 had not be collated and analysed. The interviews did reveal a number of deficiencies with respect to the operational and communication aspects of the EMS that will need to be addressed. These include:
- The roles of the EMS Coordinator, ISO14001 Steering Committee and Unit Leaders remain unclear.
- Appropriate instruction and signageremains a key issue in relation to waste and energy management.
- Orientation and training particularly for new personnel needs to be enhanced.
Internal Audit at the UNU
ISO 14001 Requirement / Relevant Section/Unit / Key Status and Observations / Internal Audit Team’s Recommendation
4.2
Environmental Policy / ISO14001 Steering Group
Unit 2 (Office of the Rector) / No issues were identified with regard to the environmental policy. All personnel have a good understanding of the environmental policy (statement) of the UNU. / The environmental policy is easy to understand and reflects the mandate and goals of the UNU. Moreover, the EMS requirements have been developed based clearly on the policy. Nevertheless, there remains some confusion about how to translate policy into action through the EMS requirements by the related personnel (including new staff and the subcontractors), particularly with respect to how to promote continual improvement of both the EMS and the UNU’s environmental performance. The Internal Audit Team recommend that a longer term perspective be adopted when considering the implementation of the EMS, perhaps in line with the Strategic Planning Process of the UNU.
4.3.1
Environmental Aspects / ISO14001 Steering Group
Each Unit / Environmental aspects were initially identified two years ago. Additional work is required in order to review the environmental aspects and if possible incorporate new aspects in consultation with UNU personnel. / Following the completion of the 2nd Environmental Review (due in February 2002), environmental aspects should be identified using the aspect assessment process. Both direct and indirect environmental aspects should be captured. Each section/unit must ensure whether their relevant environmental aspects are covered in the aspect assessment process. If possible health and safety issues should be considered.
4.3.2
Legal and other requirement / ISO14001 Steering Group
Unit 4 (Sanko Ltd)
Unit 1 (Biru Daiko) / Relevant legal requirements and compliance issues have been identified. However details need to be regularly updated. / An agreement needs to be made between the UNU and its subcontractors that includes reference to each compliance issue, clarifying and documenting (a) responsible person/s, (b) monitoring and inspection of compliance as an on-going activity, (c) training or instruction to workers, if necessary, and (d) updates to regulations.
4.3.2 Objectives and Targets / ISO14001 Steering Group / The UNU works on a biennium programme and the ISO14001 Initiative has been developed to reflect this. However, long-term objectives (over two years or even four years) could also be considered. / It is recommended that the UNU consider long-term objectives in order to facilitate continuous improvement. This may be achievable within the context of the development of the 2002 Strategic plan that will cover a four-year period.
Objectives and targets also can be included in the environment review published by the UNU.
4.3.4
Environmental management Programme / EMS Coordinator, ISO14001 Steering Group / The Environmental management programme does not contain long-term objectives. It may also be appropriate to review the actions to be implemented particularly in relation to waste and energy. / It is recommended that the UNU set long-term objectives for waste and energy.
The Environmental Programme must be amended where relevant, e.g. if a project relates to new development or modified activities (Clause 4.3.4). In particular, it should incorporate the changes to projects and the commencement of projects in the 2002-3 biennium.
4.4.1
Structure and Responsibility / EMS Coordinator, ISO14001 Steering Group and Unit Leaders / Although the EMS has been functioning throughout 2000-1, the responsibilities within the overall environmental management system remain unclear, especially for new personnel and sub-contractors. / The ISO14001 Steering Group has been working throughout the past two years to ensure that implementation of the UNU ISO14001 initiative has progressed (albeit in modest terms). Budgetary allocations have been made and approved by the UNU Council. The Steering Group is sufficiently resourced to implement its tasks.
It is recommended that the roles of the EMS coordinator and the ISO14001 Steering Group be revisited in order to ensure that the EMS related activities are properly managed and smoothly based on the PDCA cycle (preferably every two years). It is desirable that the structure and responsibilities be revised in order to better reflect the unique organizational status of the UNU in Tokyo.
In addition, further consideration should be given on how the EMS relates to other tenants in the UN House and also to the RTC/Ps. A simplified manual could be developed for this purpose.
The persons at the Unit level responsible for meeting and setting objectives and targets and their related action should be clarified (perhaps with a brief note for each unit leader).
4.4.2
Training, Awareness, and competence / ISO14001 Steering Group
Each Unit / Documentation on training needs is accessible via the UNU ISO14001 Website (online forum). However, personnel need to be made aware of the potential consequences of departure from specified operating procedures.
A training activity was organized in November 2001 and training records are available online. These records show that training for all personnel has not been conducted (due to competing schedules or missions for many personnel). A follow-up system for staff failing to attend training and for new staff needs to be established. / In order to increase awareness and enhance competences additional training or awareness building measures may need to be implemented for all relevant personnel. These measures should be designed to ensure that personnel fully recognize and understand the structure of EMS (environmental policy, unit specific significant environmental aspects, objectives and targets, management programmes, and organizational responsibilities).
Some new personnel were not fully conversant with the EMS and hence an orientation/induction process should be developed for all on-campus personnel that includes reference to the UNU ISO14001 EMS.
This could include:
- importance of compliance with policy, procedures and requirements of the UNU environmental management system
- significant environmental aspects
- objectives and targets
- environmental benefits of improved performance
- roles and responsibilities
- requirement of EMS including emergency preparedness
- the potential consequences of departure from specified operating procedures
4.4.3
Communications / ISO14001 Steering Group / An environmental report was in preparation at the time of the Internal Audit and will be issued to the UNU personnel and the public when completed. / More active external communication may be necessary such as dissemination of the environmental policy and objectives of the UNU and general environmental awareness to visitors. GEIC, the library or other sections of the UNU may conduct these activities.
It must be ensured that all internal and external communication systems work appropriately. A mechanism for ensuring response to external requests for environmental information should be considered.
4.4.4
Environmental management system documentation / ISO14001 Steering Group
Each Unit / General documentation has been established.
Staff indicated that they had not received enough information on the outcomes of EMS related activities. As such, summary results of the environmental review and records of activities (e.g. waste records, energy consumption patterns, etc.) should be regularly disseminated to all personnel, so that they are aware of the effectiveness (or lack of) and impacts of their actions.
The UNU ISO14001 website is an important information source for the EMS and contains all up to date documentation. However, it is unclear how frequently UNU personnel visit the site and also whether they access the most recent documents. / More active communication may be necessary between the EMS coordinator and the ISO14001 Steering Group in managing daily activities based on the PDCA cycle. Appropriate measures need to be taken in order to ensure that active communication on the EMS among relevant personnel (particularly unit leaders). It is also recommended that the ISO14001 Steering Group meet with subcontractors on a regular basis, in order to exchange information and views on the status of EMS implementation.
Related to the above, the UNU ISO14001 Steering Group should develop an ISO14001 Calendar for the UNU to indicate the key events that will occur on a month by month basis.
It is recommended that some form of feedback mechanism be set up from the website in addition to the online forum which seems currently to be under-utilized.
Appropriate support needs to be provided for those personnel and subcontractors who need explanation materials and instruction in Japanese. Currently, most of the information on UNU EMS is available only in English. However, it is desirable that the Japanese summary of the information should always be provided.
Regular (perhaps annual) updating of the signage is required in order to keep the initiative fresh in the minds of UNU personnel and UN House tenants.
It is recommended that communication on UNU ISO14001 initiative be better integrated with the publications from the UNU Public Affairs, UNU Press and the UNU Annual Report (note: section of the 2002 UNU annual report does deal specifically with ISO14001 but we may need to add text on the report cover stating that the UNU is a certified ISO14001 institution).
Senior management should explore and take advantage of various forums as a means to promote ISO14001 within the UN system.
4.4.5
Document control / ISO14001 Steering Group / The guidance to staff on energy and waste management issues needs to be upgraded. / Green purchasing guidelines were issued in May 2001. Additional instructions/guidelines may be appropriate for waste and energy since their absence could lead to deviations from the policy, and objectives and targets
4.4.6
Operational control / Each Unit / The UNU had not completed the PDCA in 2001. This relates to the UNU’s internal management and reporting procedures. A better match between the ISO14001 requirements and the existing UNU management systems may need to be considered. / A one-year PDCA does not appear to suit the operational management system of the UNU and we may need to consider setting up an biannual system that follows the regular UNU reporting procedures.
Although environmental protection initiatives (waste separation, etc.) have been carried out by individual staff members, it is recommended that the need to carry out these activities based on the EMS be better clarified and clearly understood by each individual. The relevant personnel need to be aware of the significance of their activities for the EMS, so that the activities be more effectively integrated into the PDCA cycle.
Related to this there may be need for concise energy and waste management plans to be developed in collaboration with the sub-contractors.
It is recommended that the related procedures and requirements of UNU EMS for subcontractors be documented in the agreements/contracts between UNU and subcontractors.
The research programme of the UNU remains a central contributing factor to the EMS. However, more work may be required in order to elaborate on the outcomes of the UNU’s environment related research activities and future plans.
4.4.7
Emergency preparedness and response / ISO14001 Steering Group
Each Unit / A fire drill was implemented on 26 February 2001 in cooperation with the local fire department. A report on the drill is avialable from the UNU Personnel Officer. An evacuation aide memoire for staff in the UN house has been developed and circulated via email. / As per the recommendation of the 2000 internal audit, the documentation related to UNU emergency preparedness has been upgraded and circulated and contains information on key personnel in the UNU as well as emergency teams and responsibility.
Additional information to be included are:
- contacts in local authority (e.g. local fire department)
- communication plans (e.g. contacting the adjacent building including UNU/IAS).
4.5.1
Monitoring and measurement / ISO14001 Steering Group
Unit 4 (Sanko Ltd) / Monitoring and measurement activities have been conducted by Sanko Ltd and Biru Daiko. / UNU should periodically check (once per year) that sub-contractors are monitoring of the key characteristics of the operations and activities must be conducted. (e.g. electricity, gas, water consumption) and legal requirements clarified and complied with.
4.5.2
Non-conformance and corrective action / ISO14001 Steering Group
Each Unit / Non-conformances from stage 2 audit conducted by the certification company were fully corrected. / No recommendation.
4.5.3
Records / Each Unit / Unit 1 and 4 (Sanko Ltd) have a good record keeping system for monitoring of their activities. / No recommendation.
4.5.4
Environmental management system audit / ISO14001 Steering Group / Thefirst internal audit (Internal Audit 2000) was conducted on 21st and 22nd September 2000. The report is accessible via the UNU Website.
The second Internal Audit was conducted on 31st January to 4th February 2002. / Internal audit results are reported to top management (SOM) for review as per clause 4.6.
The Internal Audit 2000, recommened that more frequent internal audits (more than one per year) be undertaken. While recognizing the importance of the internal auditing in raising environmental awareness of all staff, this is not feasible with the current work demands and personnel resources of the UNU. In addition, SOM members did not accept the recommendation that more frequent audits be undertaken. For an organization of the UNU's size and with the existing significant environmental aspects, it was considered that an audit be undertaken only once per year or once every two years if appropriate.
4.6
Management review / ISO14001 Steering Group
Unit 3 / A management review of the EMS was undertaken in 12 October 2000.
A second management review is planned in March 2002. / The summary of the outcome from the Management Review was circulated to all UNU personnel via email and is assessable via the UNU ISO14001 website.
ISO14001 Internal Audit TeamThe United Nations University – Page 1