CASE STUDY 6

Massachusetts Highway Department (Mass Highway)

Environmental Management System

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CASE STUDY 6

Massachusetts Highway Department (MassHighway) *Environmental Management System*
STATUS	Implemented.
FOCUS	Operation and maintenance activities at depot facilities.
DOT’s BASIS FOR SELECTION OF FOCUS	In 1994, in response to an Administrative Consent Order (remediation costs >$50 million) with the Department of Environmental Protection, MassHighway began a comprehensive environmental compliance initiative at its maintenance facilities. Six major compliance programs were identified and EMS procedures, processes, and tools developed for: Hazardous Waste, Wetlands, Hazardous Materials, Underground Storage Tanks, Water Quality, and Solid Waste.
RELEVANCE TO THE EMS PROCESS ROADMAP	MassHighway uses the Plan – Do – Check – Act process (and, in turn, many of the steps presented in the Process Roadmap) in developing and implementing their EMS.
ACCOMPLISHMENTS AND BENEFITS	· MassHighway managers have noticed an increased environmental awareness in the substantial majority of maintenance employees. This awareness, coupled with environmental procedures, responsibilities, training, and assessments, helps Mass Highway prevent environmental problems and makes it easier to correct such problems when they do occur. This, in turn, reduces costs of compliance (including potential fines) and corrective actions. · The EMS has led to improved relations with regulatory authorities (thus easing oversight and permitting burdens and delays) and has helped MassHighway preserve its mission.
KEYS to SUCCESS	· Efforts to develop this system were supported by the Secretary of the Executive Office of Transportation and Construction (EOTC), the Commissioner of MassHighway, and senior management by declaring the EMS as a goal through the Massachusetts Managing for Results Initiative Program . · While considerable time has been invested in planning how the system should work, the Agency recognizes that the EMS must be dynamic and adaptive to regulatory and operational changes. · The Agency also recognized that continued environmental compliance is dependent upon the development of clear lines of authority, responsibility and accountability for environmental management and identification and allocation of adequate funding. · Involved personnel (including managers and staff) from across the organization and the state in efforts. · Communication of expectations, goals, requirements, and procedures to all involved employees ensures that personnel know what is expected and builds consistency. “You cannot communicate enough…” · Use existing methods and procedures, as much as possible with minor modifications as needed, to accomplish what you want to do – this builds acceptance and reduces the need to create new processes. Most people do not accept change readily.

Massachusetts Highway Department (MassHighway)

Environmental Management System

STATUS

Implemented.

FOCUS

Operation and maintenance activities at depot facilities.

DOT’s BASIS FOR SELECTION OF FOCUS

In 1994, in response to an Administrative Consent Order (remediation costs >$50 million) with the Department of Environmental Protection, MassHighway began a comprehensive environmental compliance initiative at its maintenance facilities. Six major compliance programs were identified and EMS procedures, processes, and tools developed for: Hazardous Waste, Wetlands, Hazardous Materials, Underground Storage Tanks, Water Quality, and Solid Waste.

RELEVANCE TO THE EMS PROCESS ROADMAP

MassHighway uses the Plan – Do – Check – Act process (and, in turn, many of the steps presented in the Process Roadmap) in developing and implementing their EMS.

ACCOMPLISHMENTS AND BENEFITS

· MassHighway managers have noticed an increased environmental awareness in the substantial majority of maintenance employees. This awareness, coupled with environmental procedures, responsibilities, training, and assessments, helps Mass Highway prevent environmental problems and makes it easier to correct such problems when they do occur. This, in turn, reduces costs of compliance (including potential fines) and corrective actions.

· The EMS has led to improved relations with regulatory authorities (thus easing oversight and permitting burdens and delays) and has helped MassHighway preserve its mission.

KEYS to SUCCESS

· Efforts to develop this system were supported by the Secretary of the Executive Office of Transportation and Construction (EOTC), the Commissioner of MassHighway, and senior management by declaring the EMS as a goal through the Massachusetts Managing for Results Initiative Program .

· While considerable time has been invested in planning how the system should work, the Agency recognizes that the EMS must be dynamic and adaptive to regulatory and operational changes.

· The Agency also recognized that continued environmental compliance is dependent upon the development of clear lines of authority, responsibility and accountability for environmental management and identification and allocation of adequate funding.

· Involved personnel (including managers and staff) from across the organization and the state in efforts.

· Communication of expectations, goals, requirements, and procedures to all involved employees ensures that personnel know what is expected and builds consistency. “You cannot communicate enough…”

· Use existing methods and procedures, as much as possible with minor modifications as needed, to accomplish what you want to do – this builds acceptance and reduces the need to create new processes. Most people do not accept change readily.

CASE STUDY 6

Massachusetts Highway Department (MassHighway) *Environmental Management System*
KEYS to SUCCESS (cont’d)	· MassHighway elected to develop programs to achieve compliance in advance of adopting the formal EMS. This was in part due to regulatory pressure but also allowed the EMS to encompass already existing programs that employees had been using.
IMPLEMENTATION NEEDS	· Needed to identify expected costs and benefits to obtain resources and commitment with the development of an Implementation Plan. · Consultant support was needed to assist in EMS development and implementation . · Training and other communications were needed to raise the environmental awareness of employees and are still needed to maintain awareness. · The EMS efforts required the support of approximately 10 Central Office and Field staff. · Consultant recourses are currently needed to inventory all permits to be logged into a web-based tracking database “EnviroTrac”, and to support other special projects such Spill Prevention Countermeasure and Control Plan development at selected Facilities.
BACKGROUND, ADDITIONAL INFO	By assessing its facilities MassHighway established that there were many issues relative to environmental compliance one of the most visible was the improper storage of hazardous waste. The Governor and the Executive Office of Environmental Affairs further required that all agencies perform environmental audits of their respective facilities. It became clear that it made sense to keep the facilities in proper order and develop sustainable methods of operation. The EMS was created sustain environmental compliance with respective its depot facilities. · In the mid-90s, MassHighway performed a gap analysis to evaluate MassHighway’s management structure and to determine the level of environmental compliance. 600 aspects were reduced to 6 compliance priority areas. · The gap analysis concluded that a significant financial and personnel investment was needed to correct violations of regulatory requirements and to provide a method to ensure on-going compliance. EMS became a tool to ensure compliance and realize savings in fines and supplemental environmental projects to preserve mission, while increasing consistency and understanding. · Separate Management System Improvement and Implementation Plans were prepared. Together these plans outlined the programs and funding needed to achieve environmental compliance. During the development of these plans it was determined that the majority of the funding for environmental compliance would be directed toward “cleaning up” the previously accumulated wastes located at the facilities. o Under the Hazardous Waste and Solid Waste Programs, these wastes were removed and either properly disposed of or recycled. New waste/material storage areas and equipment for spill management were also provided through the Hazardous Material Program.

Massachusetts Highway Department (MassHighway)

Environmental Management System

KEYS to SUCCESS (cont’d)

· MassHighway elected to develop programs to achieve compliance in advance of adopting the formal EMS. This was in part due to regulatory pressure but also allowed the EMS to encompass already existing programs that employees had been using.

IMPLEMENTATION NEEDS

· Needed to identify expected costs and benefits to obtain resources and commitment with the development of an Implementation Plan.

· Consultant support was needed to assist in EMS development and implementation .

· Training and other communications were needed to raise the environmental awareness of employees and are still needed to maintain awareness.

· The EMS efforts required the support of approximately 10 Central Office and Field staff.

· Consultant recourses are currently needed to inventory all permits to be logged into a web-based tracking database “EnviroTrac”, and to support other special projects such Spill Prevention Countermeasure and Control Plan development at selected Facilities.

BACKGROUND, ADDITIONAL INFO

By assessing its facilities MassHighway established that there were many issues relative to environmental compliance one of the most visible was the improper storage of hazardous waste. The Governor and the Executive Office of Environmental Affairs further required that all agencies perform environmental audits of their respective facilities. It became clear that it made sense to keep the facilities in proper order and develop sustainable methods of operation. The EMS was created sustain environmental compliance with respective its depot facilities.

· In the mid-90s, MassHighway performed a gap analysis to evaluate MassHighway’s management structure and to determine the level of environmental compliance. 600 aspects were reduced to 6 compliance priority areas.

· The gap analysis concluded that a significant financial and personnel investment was needed to correct violations of regulatory requirements and to provide a method to ensure on-going compliance. EMS became a tool to ensure compliance and realize savings in fines and supplemental environmental projects to preserve mission, while increasing consistency and understanding.

· Separate Management System Improvement and Implementation Plans were prepared. Together these plans outlined the programs and funding needed to achieve environmental compliance. During the development of these plans it was determined that the majority of the funding for environmental compliance would be directed toward “cleaning up” the previously accumulated wastes located at the facilities.

o Under the Hazardous Waste and Solid Waste Programs, these wastes were removed and either properly disposed of or recycled. New waste/material storage areas and equipment for spill management were also provided through the Hazardous Material Program.

CASE STUDY 6

Massachusetts Department of Transportation (Mass Highway) *Environmental Management System*
BACKGROUND, ADDITIONAL INFO (cont’d)	o The Water Quality Program provided for facility improvements such as septic system upgrades/installation, sewer connections, floor drain upgrades and the installation of wash water recycling systems. o The Wetland Program provided for the identification of impacts to wetlands, and the implementation of corrective actions. o The Tank Program replaced or upgraded all USTs to meet Federal standards. Subsequent to the development of the management plans, an additional compliance program was instituted for managing asbestos issues and is currently responsible for inspection and abatement of known locations of asbestos and requires the oversight of the Statewide and District Asbestos Coordinators during facility demolition and renovation projects. · MassHighway published a Facility Environmental Handbook particular to each facility. This handbook is a reference document that provides guidance on conducting operations in compliance with environmental requirements. It contains standard operating procedures and maps to identify structures and environmentally sensitive areas such as wetlands. The handbook is used to train MassHighway personnel on an annual basis and raise the level of environmental awareness. The department also has an EMS manual and 20 operating procedures and is developing a website. · A committee with District Maintenance Engineers was established to define roles, which are reviewed annually during training events for all facility personnel (training in off season time). MassHighway’s Standard Operating Procedures references these roles and responsibilities. · In developing the EMS, MassHighway used existing methods and procedures to accomplish wants with minimum (/) modifications.
CONTACT(S)	Mr. Steven Miller, Supervisor, Hazardous Materials Section, 617/973-8248, smiller@mhd.state.ma.us
EXAMPLE TOOLS, PROCEDURES	A key to the success of any EMS is the commitment of senior management. Exhibit 1, A Commitment to the Environment, demonstrates this commitment in MassHighway and explains the significance of the EMS. Mass Highway has prepared an EMS Manual which captures its EMS procedures, processes, and tools. Following are descriptions of excerpts from this Manual. · Exhibit 2 provides the Table of Contents. · Exhibit 3 presents the EMS Manual’s Executive Summary. This section provides background on the EMS and explains EMS goals, procedures, processes, and tools. PLEASE NOTE: the Executive Summary embodies the Plan – Do – Check – Act process described in the AASHTO EMS Process Roadmap. · Exhibit 4 provides an excerpt that identifies District Roles and Responsibilities. This excerpt illustrates the need to clearly identify and communicate environmental roles and responsibilities.

Massachusetts Department of Transportation (Mass Highway)

Environmental Management System

BACKGROUND, ADDITIONAL INFO (cont’d)

o The Water Quality Program provided for facility improvements such as septic system upgrades/installation, sewer connections, floor drain upgrades and the installation of wash water recycling systems.

o The Wetland Program provided for the identification of impacts to wetlands, and the implementation of corrective actions.

o The Tank Program replaced or upgraded all USTs to meet Federal standards.

Subsequent to the development of the management plans, an additional compliance program was instituted for managing asbestos issues and is currently responsible for inspection and abatement of known locations of asbestos and requires the oversight of the Statewide and District Asbestos Coordinators during facility demolition and renovation projects.

· MassHighway published a Facility Environmental Handbook particular to each facility. This handbook is a reference document that provides guidance on conducting operations in compliance with environmental requirements. It contains standard operating procedures and maps to identify structures and environmentally sensitive areas such as wetlands. The handbook is used to train MassHighway personnel on an annual basis and raise the level of environmental awareness. The department also has an EMS manual and 20 operating procedures and is developing a website.

· A committee with District Maintenance Engineers was established to define roles, which are reviewed annually during training events for all facility personnel (training in off season time). MassHighway’s Standard Operating Procedures references these roles and responsibilities.

· In developing the EMS, MassHighway used existing methods and procedures to accomplish wants with minimum (/) modifications.

CONTACT(S)

Mr. Steven Miller, Supervisor, Hazardous Materials Section, 617/973-8248, smiller@mhd.state.ma.us

EXAMPLE TOOLS, PROCEDURES

A key to the success of any EMS is the commitment of senior management. Exhibit 1, A Commitment to the Environment, demonstrates this commitment in MassHighway and explains the significance of the EMS.

Mass Highway has prepared an EMS Manual which captures its EMS procedures, processes, and tools. Following are descriptions of excerpts from this Manual.

· Exhibit 2 provides the Table of Contents.

· Exhibit 3 presents the EMS Manual’s Executive Summary. This section provides background on the EMS and explains EMS goals, procedures, processes, and tools. PLEASE NOTE: the Executive Summary embodies the Plan – Do – Check – Act process described in the AASHTO EMS Process Roadmap.

· Exhibit 4 provides an excerpt that identifies District Roles and Responsibilities. This excerpt illustrates the need to clearly identify and communicate environmental roles and responsibilities.

CASE STUDY 6

Massachusetts Department of Transportation (Mass Highway) *Environmental Management System*
EXAMPLE TOOLS, PROCEDURES (cont’d)	· Exhibit 5 presents an excerpt describing training requirements. Training is a key to understanding and implementing environmental requirements and EMS procedures. · Exhibit 6 provides an excerpt that describes another key element of a successful EMS – self auditing. Following are excerpts of procedures and tools that MassHighway uses to implement its EMS. · Exhibit 7 shows the Self Audit Checklist used during the annual facility self audit. This checklist is provided in the Self Audit Procedure Fieldbook. · Exhibit 8 presents an excerpt of the Regular Inspection Checklist which is used to periodically inspect for compliance violations and initiate corrective actions if needed. · Exhibits 9 through 12 provide examples of Standard Operating Procedures which are used by field personal as a tool to support compliance and Agency goals. There are 24 such procedures.

Massachusetts Department of Transportation (Mass Highway)

Environmental Management System

EXAMPLE TOOLS, PROCEDURES (cont’d)

· Exhibit 5 presents an excerpt describing training requirements. Training is a key to understanding and implementing environmental requirements and EMS procedures.

· Exhibit 6 provides an excerpt that describes another key element of a successful EMS – self auditing.

Following are excerpts of procedures and tools that MassHighway uses to implement its EMS.

· Exhibit 7 shows the Self Audit Checklist used during the annual facility self audit. This checklist is provided in the Self Audit Procedure Fieldbook.

· Exhibit 8 presents an excerpt of the Regular Inspection Checklist which is used to periodically inspect for compliance violations and initiate corrective actions if needed.

· Exhibits 9 through 12 provide examples of Standard Operating Procedures which are used by field personal as a tool to support compliance and Agency goals. There are 24 such procedures.

CASE STUDY 6

Exhibit 1

CASE STUDY 6

Exhibit 2

Table of Contents

Environmental Commitment

Executive Summary

SECTION I – General Roles and Responsibilities

Executive Office of Transportation and Construction..................................... 1

Commissioner.................................................................................................... 1

Chief Engineer.................................................................................................... 1

Chief Counsel..................................................................................................... 2

Administrative Services Division...................................................................... 2

Environmental Division...................................................................................... 3

Operations Division............................................................................................ 4

Construction Division......................................................................................... 5

Engineering Division.......................................................................................... 6

Right of Way Section ......................................................................................... 6

Privatization Engineer........................................................................................ 6

Research and Materials Laboratory................................................................. 6

EMS Task Force................................................................................................ 6

Districts................................................................................................................ 7

SECTION II - EMS Components

Funding....................................................................................................................... 8

Environmental Requirements............................................................................. 12

Emergency Preparedness................................................................................... 15

Standard Operating Procedures........................................................................ 18

Facility Environmental Handbook and Maps.................................................. 20

Training..................................................................................................................... 23

Compliance Tracking............................................................................................ 28

Self-Auditing............................................................................................................ 31

Pollution Prevention.............................................................................................. 35

EMS Review and Evaluation............................................................................... 37

Section III - Contacts and Information Sources

Contacts................................................................................................................... 40

Information Sources.............................................................................................. 42

CASE STUDY 6

Exhibit 3

Executive Summary

Background

In 1994, in response to an Administrative Consent Order with the Department of Environmental Protection, MassHighway began a comprehensive environmental compliance initiative at its maintenance facilities. At the outset, the department performed a gap analysis to evaluate MassHighway’s management structure and to determine the level of environmental compliance. The gap analysis concluded that a significant financial and personnel investment was needed to correct violations of regulatory requirements and to provide a method to ensure on-going compliance. The need to develop and institutionalize a formal Environmental Management System to support environmental compliance was thus identified. The efforts to develop this system were supported by senior management at MassHighway and the Executive Office of Transportation and Construction (EOTC). As a result, separate Management System Improvement and Implementation Plans were prepared. Together these plans outlined the programs and funding needed to achieve environmental compliance. During the development of these plans it was determined that the majority of the funding for environmental compliance would be directed toward “cleaning up” the previously accumulated wastes located at the facilities. Six major compliance programs were immediately created: Hazardous Waste, Wetlands, Hazardous Materials, Underground Storage Tanks, Water Quality and Solid Waste. Under the Hazardous Waste and Solid Waste Programs, these wastes were removed and either properly disposed of or recycled. New waste/material storage areas and equipment for spill management were also provided through the Hazardous Material Program. The Water Quality Program provided for facility improvements such as septic system upgrades/installation, sewer connections, floor drain upgrades and the installation of wash water recycling systems. The Wetland Program provided for the identification of impacts to wetlands and the development and implementation of corrective actions. The Tank Program replaced or upgraded all USTs to meet Federal standards. Subsequent to the development of the management plans, an additional compliance program was instituted for managing MassHighway’s asbestos issues. MassHighway further published a Facility Environmental Handbook particular to each facility. This handbook is a reference document that provides guidance on conducting operations in compliance with environmental requirements. It contains standard operating procedures and maps to identify structures and environmentally sensitive areas such as wetlands. The handbook is used to train MassHighway personnel on an annual basis and raise the level of environmental awareness.

Environmental Compliance and the EMS Manual

While providing facility staff with the appropriate tools and upgrading the facility infrastructure were important first steps, the Department also recognized that continued environmental compliance is dependent upon the development of clear lines of authority, responsibility and accountability for environmental management and identification and allocation of adequate funding. This Environmental Management System (EMS) manual serves that purpose in that it documents the lines of authority and the respective roles and responsibilities within the department. This manual also provides the framework to instill an operating awareness at all organizational levels of the importance of integrating sound environmental management practices into the operations of the Department.

MassHighway has designed the EMS in accordance with a Plan, Do, Check, Act improvement cycle. While considerable time has been invested in planning how the system should work, the Department recognizes that the EMS must be dynamic and adaptive to regulatory and operational changes. To meet this need a regular review process will be in effect to ensure that the system can be modified and continually improved to meet the Department’s objectives.

Continuous Improvement Cycle

Environmental roles and responsibilities have been assigned to all levels of MassHighway. A general description of roles and responsibilities of each Division, Section, and District is provided in Section I of this manual. Procedures for implementing each component of the system as well as a description of an employee’s specific role and responsibility is described in further detail in Section II of the manual.

MassHighway’s EMS consists of specific components which serve separate and distinct purposes but are integrated to become part of the overall system. An overview of these components is provided below.

Environmental Management System Manual Overview

EMS Component		Description
Funding	Identifies the process and responsibilities for allocating adequate funding for environmental compliance at MassHighway Facilities.
Environmental Requirements	Discusses the environmental laws and regulations that apply to operations at maintenance facilities, and the procedures for identifying proposed and new regulatory changes that affect operations at maintenance facilities.
Emergency Preparedness	Identifies the MassHighway procedures for planning and responding to spills at MassHighway facilities.
Standard Operating Procedures	Describes the methods for identifying the need for environmental standard operating procedures (SOPs) as well as the development, review, revision and, endorsement of environmental SOPs to guide facility staff on environmental management requirements.
Facility Environmental Handbook and Maps	Identifies the purpose of the Facility Environmental Handbook and Maps and, provides for the identification of the roles and responsibilities for updating the handbook.
Training	Documents the procedures for planning, delivering and tracking environmental training of MassHighway personnel that support environmental compliance.
Compliance Tracking	Defines the procedure MassHighway uses to identify, correct, and track compliance issues.
Self-Auditing	Describes the procedures for conduct of MassHighway’s program for evaluating the status and return to environmental compliance at MassHighway Facilities.
Pollution Prevention	Describes the activities MassHighway conducts to prevent pollution through conservation and reduction programs.
EMS Review and Evaluation	Describes the procedures and schedules for review and update of MassHighway’s EMS and its associated Manual.

Role	Responsibility
District Highway Director	The District Highway Director is responsible for being familiar with and overseeing the implementation of the provisions of the EMS such that the District’s roles and responsibilities are carried out in such a manner so as to maintain environmental compliance.
District Maintenance Engineer	The District Maintenance Engineer (DME) must maintain an awareness of the EMS and is responsible for coordinating facility maintenance activities in accordance the procedures of the EMS Manual. This includes ensuring that facility personnel are allotted sufficient time to perform house keeping tasks that support environmental compliance and notifying appropriate MassHighway personnel of an emergency situation at facilities in accordance with MassHighway’ s Emergency Response Plan (ERP) and Spill Prevention Control and Countermeasure (SPCC) Plans at specific facilities. Obtains and ensures compliance with all applicable permits for District facilities.
Contract Specialist III’s/Area Supervisor	The Contract Specialist III/Area Supervisor (CS III/AS) ensures that: all personnel within the Area receive yearly Annual Environmental Awareness Training; facility inspections are conducted and that corrective actions are completed as required; EMS and Environmental Program documentation (generated by Facility Foreman and personnel) such as regular inspection checklists, Stage II Vapor recovery system checklists, Hazardous Waste area inspections checklists and oil/water separator inspection reports are forwarded to the District Maintenance Engineer. Responsibilities also include: review and submittal of the facility inspection reports/self-audit findings to the DME and initiating corrections as required; scheduling work as needed at facilities to maintain compliance including: septic system pump-outs, septic system inspections, vehicle washing recycling system maintenance and holding tank and oil/water separator pump-outs. The CS III/AS is also the designated Primary Emergency Coordinator as defined by MassHighway’s Emergency Response Spill Plan.
Contract Specialist II’s/Facility Foreman	The Contract Specialist II/ Facility Foreman (CSII/FF) is responsible for ensuring that all operational activities that impact environmental compliance at District Facilities are conducted in accordance with the EMS and specifically with the provisions of the Facility Environmental Handbook. This includes maintaining proper areas for material and hazardous waste storage; using the emergency response call down procedures; adhering to guidelines presented in the Annual Environmental Awareness Training; staying current with the Environmental Standard Operating Procedures and being familiar with the location of wetlands, buffer zones and other areas of environmental concern.
Facility Personnel	The Facility Personnel are responsible for keeping work areas clean and materials and wastes stored properly, performing inspections on the Hazardous Material and Hazardous Waste storage areas, maintaining labels on material and waste containers, reporting spills of hazardous materials from machinery and heavy equipment and, attending annual refresher training related to environmental compliance.

Training	Regulation	Regulatory Requirement	Participants	Delivery
Hazardous Waste Awareness Training	310 CMR 30.351(9)(g)	Employees having responsibility for handling/managing hazardous waste at SQG facilities must be properly trained so they know how to perform their duties and so that hazardous waste handling practices and emergency procedures are performed properly and in compliance with all applicable requirements. Employees are provided initial training to a competency level with refresher training as necessary.	District Structures Maintenance Engineer, CSIII/Area Foreman, HOV Facility Personnel, CSII/Facility Foremen, Facility Personnel District HazMat Coordinators	Training provided during annual Environmental Awareness Training by DHCs
Universal Waste Training	310 CMR 30.1035	Employees having the responsibility for handling or managing universal waste shall be informed of the proper handling and emergency procedures appropriate to the types of universal waste handled at the facility. Employees are provided initial training to a competency level with refresher training as necessary.	District Structures Maintenance Engineer, CSIII/Area Foreman, HOV Facility Personnel, CSII/ Facility Foremen, Facility Personnel, District HazMat Coordinators.	Training provided during annual Environmental Awareness Training by DHCs
Department of Transportation/ General Awareness, Manifest, and Safety Training Programs	49 CFR 172.704(a) 310 CMR 30.409	Each hazmat employee* shall be provided 1) general awareness training designed to provide familiarity with the requirements of this subchapter, and to enable the employee to recognize and identify hazardous materials consistent with OSHA Hazard Communication Standard (29 CFR 1910.1200). OSHA or EPA training may be used to satisfy the requirements of 49 CFR 172.704(a) to avoid duplication of training efforts. 2) function specific training concerning the requirements of the DOT hazardous waste regulations specific to the function the employee performs. 3) safety training concerning emergency response information, measures for protection from the hazards associated with hazardous materials, and methods and procedures for avoiding accidents. Employees are provided initial training to a competency level with refresher training every 3 years thereafter.	District HazMat Coordinators, CSII/Facility Foreman	Training coordinated by Environmental Division and conducted through a consultant contract
Stage II Vapor Recovery System Inspection Training	310 CMR 7.24	Persons performing Stage II systems weekly inspections must be trained to inspect equipment including, but not limited to, nozzle boots and splash/vapor guards, hoses, hose retractors, coaxial adapters, dry breaks, fill caps, vapor recovery caps, spill containment boxes and drain valves. Employees are provided initial training to a competency level with refresher training as necessary.	CSIII, Foremen, Laborers	Training is provided by the DHCs.
Spill Prevention Control and Countermeasure (SPCC)	40 CFR 112.7(e)(10) (iii)	Employees shall be trained in the use of the SPCC, applicable pollution control laws and the operation and maintenance of equipment to prevent the discharges of oil. Employees are provided initial training to a competency level with annual refresher training.	Employees having a role in the SPCC plan for a facility	Training provided during annual Environmental Awareness Training by DHCs

CASE STUDY 6

Exhibit 6

Self-Auditing

This EMS component describes the procedures used by MassHighway during the implementation of its Self-Audit Program including conducting of the self audits, post audit reporting and follow up, and revising and updating the Self-Audit Protocol. The Self-Audit Program is intended to evaluate environmental compliance at MassHighway Maintenance Facilities and track a facility’s return to compliance through corrective action implementation. The Protocol is designed to reflect the compliance themes contained in the Facility Environmental Handbook across eight major compliance areas covering multi-media federal and state environmental regulatory programs, MassHighway SOPs, and best management practices (BMPs). Because it is designed to discover and correct environmental compliance matters, the Self-Audit Program is an integral component of MassHighway’s EMS.

MassHighway is committed to keeping the Self-Audit Protocol current. The Self-Audit Program and Protocol is reviewed at least annually to identify areas where updates and/or revisions are needed due to either regulatory or operational changes. Review of the Program is necessary to ensure continual improvement and ensure that the Protocol reflects current regulations, SOPs, and facility operations.

Procedure

This section presents an overview of the procedures and roles and responsibilities for conduct of MassHighway Self-Audits. The actual MassHighway Self-Audit Protocol Handbook is available for a detailed discussion of the procedures and roles and responsibilities. The procedures discussed below generally involve five MassHighway staff members; the Audit Coordinator, the Lead Auditor, District Maintenance Engineer, the Facility Forman and the District HazMat Coordinator. There are three Phases to a MassHighway Self-Audit; the Pre-audit Preparation, the Audit Site Visit and the Post Audit Phase. The process is described below.

Pre-audit Preparation. The Audit Coordinator prepares a schedule for facility audits. Once the schedule has been prepared, the Audit Coordinator will designate a DHC as the District Lead Auditor. The Lead Auditor will be a DHC from a District other than the one being audited. The Lead Auditors are provided with facility and District contact information needed to complete the self-audit notifications, site visit, and follow up reporting. The Lead Auditor will notify the DHC and DME in the District of the scheduled audit at least two weeks in advance of the audit. The DHC and DME will ensure pre audit questionnaires are completed, Facility foremen are contacted, and that facility records are made available at the time of the audit.

Audit Site Visit. The Lead Auditor will conduct a pre-audit briefing with facility personnel to 1) inform facility personnel of the purpose of the audit; 2) inform facility personnel of their audit responsibilities and required participation in the audit; and 3) answer any preliminary questions the facility personnel may have regarding the audit. After the briefing, the Lead Auditor conducts a facility walkthrough, recording any environmental compliance findings in field notes and facility plans. The Lead Auditor also performs a record review of applicable compliance documents, such as manifests and environmental permits. During the walkthrough and records review, the Lead Auditor completes the Audit Protocol Checklist. Findings that may be immediately corrected should be completed during the walkthrough and documented by the auditor. The Lead Auditor then conducts exit briefings and submits the draft findings list to the Facility Foreman at the completion of each audit. The list is provided so facility personnel may initiate corrective actions in advance of receiving a Corrective Action Report (CAR).

Post Audit Phase. Following the audit site visit, the Lead Auditor prepares a CAR, which summarizes the audit findings. An electronic version is forwarded to the Audit Coordinator and the DME. Upon receipt of the CAR, the DME coordinates with the facility foreman to ensure facility personnel conduct the necessary corrective actions. DHCs are responsible for correcting or managing corrective actions that fall outside operational responsibility of the Facility Foreman or DME.

The Facility Foreman ensures that the corrective actions have been completed and documents corrective actions in the space provided on the CAR. The completed CAR is forwarded to the Lead Auditor for review and confirms that the completed actions adequately address the findings on the CAR. The completed CAR is forwarded to the Audit Coordinator along with a memo that summarizes the completed self-audit.

For each unresolved regulatory finding, the Lead Auditor completes a Clean State Matter Report (CSMR). If a completed CAR has not been received within 14 days of the audit a CSMR is completed for all regulatory findings identified on the original CAR. Within two days of receiving the completed CAR, the Lead Auditor forwards all audit field notes, checklists, completed CAR, and CSMRs to the Audit Coordinator for archiving in the Environmental Division’s Self-Audit Program files. The Audit Coordinator will enter all unresolved regulatory findings documented on the CSMRs into the EOEA’s Clean State Database.

The Audit Coordinator provides the audit findings to the DHC. The DHC will complete and transmit to the Audit Coordinator and DME a Corrective Action Plan (CAP) for each unresolved regulatory finding on the completed CAR. The DHC will provide quarterly CAP progress reports to the Audit Coordinator until the CAP has been completely resolved. The Audit Coordinator will enter the updates into the Clean State database. Once a CAP has been completely resolved, the Audit Coordinator will complete and submit a request for de-listing of a regulatory finding from the EOEA’s Clean State Coordinator and the Clean State database.

A summary of the timelines described in the preceding sections for conducting Self-Audits and audit follow-up activities is provided below.

Activity	Responsible Person	Timeline
Assign Audit Team and Lead Auditor	Audit Coordinator	According to Annual Schedule
Notify DHC, DME, and Facility foreman of impending Self-Audit	Lead Auditor	At least two weeks before audit site visit date
Complete and submit CAR to DHC, DME, and Foreman	Lead Auditor	Within two days after audit site visit.
Complete and submit CAR and CCAR to Lead Auditor	Foreman/DHC	Within 14 days of the date the audit was conducted
Complete audit summary memo and CSMRs and submit to Audit Coordinator	Lead Auditor	Within 2 days after receipt of CCAR or within 2 days of CCAR due date
Enter audit results into Clean State database and submit final CAR to DHC	Audit Coordinator	Within 2 days after receipt of CCAR from Lead Auditor
Complete Corrective Action Plan	DHC	Within 21 days after receipt of final CCAR from Audit Coordinator
Complete CAP Progress Reports	DHC	Quarterly – ongoing until Final CAP Completion Report issued
Update of Clean State database	Audit Coordinator	Quarterly – ongoing until Final CAP Completion Report issued

Self-Audit Process Timelines

CASE STUDY 6

Exhibit 7

Audit Checklist

Facility Information

Facility Name:

Address:

City, State, Zip:

Type of Facility:

Facility Representative:

Title:

Telephone:

Fax:

Auditing Information

Regulated Activities

Date of Audit:

Lead Auditor:

District Hazmat Coordinator:

Persons Interviewed:

Inaccessible Areas:

General Comments:

Vehicle Fueling

Vehicle Washing

Wastewater Recycling System

Industrial Wastewater Discharge

Oil Water Separator

Industrial Wastewater Holding Tank

Waste Oil Generation

RCRA Hazardous Waste Generation

Universal Waste Generation

Hazardous Materials Use/Storage

Solid Waste Accumulation

On-Site Sewage Disposal

On-Site Drinking Water Well

Natural Resources: wetlands waterways

USTs ASTs

MCP Site

Pre-Existing Clean State Matters

Other:

Facility Operations

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*Regulatory Areas and Compliance Checklists*
Section 1: HAZARDOUS WASTE
YES	NO	N/A	Verification of Generator Status: (310 CMR30.060 & 30.303)
			Has the facility registered as a Generator of Hazardous Waste and/or Waste Oil? Generator ID No:
			Facility Hazardous Waste Generator Status: VSQG SQG Facility Waste Oil Generator Status: VSQG SQG
			Is the registered generator status appropriate? (VSQG <100 kg/mo.; SQG <1,000 kg/mo. - review manifests)
			Have appropriate hazardous waste determinations been made for wastes generated at the facility?
			*IF VSQG: (310 CMR 30.253 & 30.353)*
			Are there less than three 55-gallon drums of hazardous waste/waste oil at the facility?
			*IF SQG: (310 CMR30.253 & 30.351)*
			Are there less than ten 55-gallon drums of hazardous waste/waste oil at the facility?
			*IF DUAL STATUS* (e.g. VSQG of hazardous waste and SQG of waste oil):
			Are the quantities of hazardous waste and waste oil stored at the facility below the maximum allowed for each status? (e.g. < 3 drums of hazardous waste and < 10 drums of waste oil)
			Waste Container Management: (310 CMR 30.253; 30.351; 30.353)
			Are all hazardous waste containers in good condition? (Note any dents, rust, or damage)
			Are all hazardous waste containers tightly closed (bungs sealed and bolt ring secured, except when adding/removing waste)?
			Are all hazardous waste containers labeled?
			Do the labels include the name of the waste (waste oil, waste paint, etc.)?
			Is the waste Hazard Type (toxic, ignitable, corrosive, and/or reactive) included on each label?
			If the facility is a Small Quantity Generator, is the date when accumulation began clearly marked on the container label?
			Is the accumulation time within regulatory limits? (180-days SQG)
			Are containers compatible with the waste being accumulated?
			Are containers of hazardous waste stored in the designated accumulation area?
			Hazardous Waste Accumulation Areas: (310 CMR 30.253; 30.351; 30.353; 30.322)
			*If the facility maintains a Hazardous Waste Accumulation Area:*
			Is the accumulation area locked/secured to prevent unknowing entry?
			Is the accumulation area adequately demarcated? ( e.g., visible yellow line on floor and only HW stored therein)
			Is the accumulation area located on a surface free of cracks and, if not on containment, away from floor drains?
			Is the accumulation area labeled as “HAZARDOUS WASTE” with lettering at least 1-inch high?
			Is Emergency Information/Contact List posted at the accumulation area?
			Is emergency equipment (spill, fire, etc.) located at the accumulation areas?
			Is secondary containment in use where required/warranted? (e.g., if located outside or near floor drains, etc.)
			Is the accumulation area in good order (clean and neat, free of spills)?
			Does the area have adequate aisle space between drums to allow for inspections of the containers?
			*If the facility does NOT maintain a Hazardous Waste Accumulation Area:*
			Is the waste transported to a designated facility on the day of generation or within 3 days of filling a Satellite Drum?