UTM DREDGING LIMITED

Non conformance And Corrective And

Preventive Action

Guidance ................................................................................................................................... 15-2

Figure 15-1: Root Cause Diagram ............................................................................... 15-3

Tools and Forms ....................................................................................................................... 15-6

Tool 15-1: Corrective & Preventive Action Worksheet ............................................... 15-6

Tool 15-2: Sample Procedure for Corrective and Preventive Action........................... 15-7
Form 15-2a: Sample Corrective and Preventive Action Notice .................................. 15-9
Form 15-2b: Sample Corrective and Preventive Action Tracking Log..................... 15-10
EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 1
EMS Template
Revision 2.0 (March 2002)

GUIDANCE

No EMS is perfect. You will probably identify problems with your system (especially in the
early phases) through audits, measurement, or other activities. In addition, your EMS will need
to change as your organization adapts and grows. To deal with system deficiencies, your
organization needs a process to ensure that:

1. Problems (including nonconformities) are Key

Steps
identified and investigated;
2. Root causes are identified; identify the problem
3. Corrective and preventive actions are identified and investigate to
implemented; and, identify the root cause
4. Actions are tracked and their effectiveness is verified. come up with solution
implement solution
EMS nonconformities and other system deficiencies (such document solution
as legal noncompliance) should be analyzed to detect communicate solution
patterns or trends . Identifying trends allows you to evaluate
anticipate and prevent future problems. effectiveness of
solution
Focus on correcting and preventing problems. Preventing
problems is generally cheaper than fixing them after they
occur (or after they reoccur). Start thinking about problems as
opportunities to improve! Why do EMS
problems occur?
Typical causes include:
Determining Causes of Problems
You will need to establish a method to determine the causes poor communication
of faulty or missing
failing to meet a target. In some cases, the cause might not procedur
be difficult to understand. Other times, however, the cause es
might not be obvious. equipment malfunction
(or lack of maintenance)

One method is called “root cause analysis.” This method lack of training
can be applied to identify causes for not meeting targets. lack of understanding
(of
You can also use it to determine the possible causes of a requirements)
potential impact. You should determine the root cause of failure to enforce rules
each of your SEAs that has an impact on the environment.
corrective actions fail to
For example, if a spill occurs several times in your raw address root causes
material transfer area, you should attempt to identify why of problems
the spill is occurring – that is, the root cause – so you can
address the cause and prevent the spill in the future.
EMS Corrective and Prevention Action, Management Review, and Continuous Improvement
Module 15 - 2
EMS Template
Revision 2.0 (March 2002)

The root cause diagram, shown in Figure 15-1, will help you organize your thinking when you
analyze your company’s potential for environmental impact. This analysis can be done by one
person or by a group, with one person writing down the ideas produced. Each diagonal line
represents a main component of the production process. Each horizontal line stemming from the
diagonal represents an important element contributing to each of the main components. For
example, elements of work practices might contribute to the labor component. This diagram is
simply a device to help organize the analysis of the cause of potential environmental impacts.
Use it if it helps, but don’t get hung up on trying to make it work.

Figure 15-1: Root Cause Diagram

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 3
EMS Template
Revision 2.0 (March 2002)

Taking corrective action

Once you document a problem with respect to meeting targets, you must resolve it. Take action
as quickly as possible. Make sure assigned responsibilities for actions and schedules are clear so
that correction occurs in a timely manner.

Employees in the shop may recognize the need for corrective action and provide good ideas for
solving problems. Find ways to get them involved in the improvement process. It’s important to
determine whether a lapse is temporary or due to some flaw in the procedures or controls. For
this reason, communicate any findings to employees, and provide any follow-up training for
changes in the procedures that may result. The following is a checklist to help complete
corrective action. Have you:

Identified the problem(s)?

Identified the cause(s)?
Come up with a solution for each?
Implemented the solution(s)?
Documented the solution(s)?
Communicated the solution(s)?
Documented the action(s)?

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 4
EMS Template
Revision 2.0 (March 2002)

Rule of thumb: Corrective actions should (1) resolve the immediate problem, (2)
consider whether the same or similar problems exist elsewhere in the organization, and
(3) prevent the problem from recurring. The corrective action process also should define
the responsibilities and schedules associated with these three steps.
Initially, most EMS problems may be identified by your internal auditors. However, over
the long run, many problems and good ideas may be identified by the people doing the
work. This should be encouraged. Find ways to get employees involved in the system
improvement process (for example, via suggestion boxes, contests, or incentive
programs).

Tool 15-1 is a worksheet that might guide your facility in establishing and implementing a
corrective and preventive action program. Tool 15-2 provides a sample procedure for
conducting corrective and preventive action. Form 15-2a is a sample form that can be used to
document the use of your procedure. Form 15-2b can be used to track corrective and preventive
actions. Form 15-2a could also be combined with the EMS Audit Findings, Form 17-2e (see
Module 17).

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 5
EMS Template
Revision 2.0 (March 2002)

TOOLS

Tool 15-1: Corrective & Preventive Action Worksheet

Do we have an existing process for corrective and

preventive action?

If yes, does that process need to be revised? In what

way?

Who needs to be involved in this process within our

organization?

How are nonconformities and other potential system

deficiencies identified? (List methods such as audits,
employee suggestions, ongoing monitoring, etc.)

How do we determine the causes of nonconformities

and other system deficiencies? How is this
information used?

How do we track the status of our corrective and

preventive actions?

How is / can information on nonconformities and

corrective actions be used within the EMS (for
example, in management review meetings, in
employee training sessions, in review of procedures,
etc.)

How do we ensure the effectiveness of our corrective

and preventive actions?

Our next step on corrective and preventive a ction is

to …

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 6
EMS Template
Revision 2.0 (March 2002)

Tool 15-2: Sample Procedure for Corrective and Preventive Action

Purpose
The purpose of this procedure is to establish and outline the process for identifying,
documenting, analyzing, and implementing preventive and corrective actions.

Scope
Preventive or corrective actions may be initiated using this procedure for any environmental
problem affecting the organization.

General
A. Corrective action is generally a reactive process used to address problems after they have
occurred. Corrective action is initiated using the CAPAN, Form 15-2a, as the primary
vehicle for communication. Corrective action may be triggered by a variety of events,
including internal audits and management reviews. Other items that might result in a
corrective CAPAN include neighbor complaints or the results of monitoring and
measurement.

B. Preventive action is generally a proactive process intended to prevent potential problems

before they occur or become more severe. Preventive action also is initiated using the
CAPAN, Form 15-2a. Preventive action focuses on identifying negative trends and
addressing them before they become significant. Events that might trigger a preventive
CAPAN include monitoring and measurement, trends analysis, tracking of progress on
achieving objectives and targets, response to emergencies and near misses, and customer or
neighbor complaints, among other events.

C. CAPAN’s are prepared, managed, and tracked using the preventive and corrective action
database.

D. The EMR (or designee) is responsible for reviewing issues affecting the EMS, the application
and maintenance of this procedure, and any updates to EMS documents affected by the
preventive and corrective actions.

E. The EMR is responsible for logging the CAPAN into the database, and tracking and recording
submission of solutions in the database. The requester and recipient of the CAPAN
responsible for verifying the effectiveness of the solution. The EMR is responsible for
overall tracking and reporting on preventive and corrective actions.

F. Personnel receiving CAPANs are responsible for instituting the required corrective or
preventive action, reporting completion of the required action to the EMR, and assuring
sustained effectiveness.

G. Completed records of CAPANs are maintained in the database for at least two years after
completion of the corrective or preventive action.

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 7
EMS Template
Revision 2.0 (March 2002)

Procedure
A. Issuing a CAPAN

1. Any employee may request a CAPAN. The employee requesting the CAPAN is
responsible for bringing the problem to the attention of the EMR. The EMR is
responsible for determining whether a CAPAN is appropriate and enters the appropriate
information into the corrective and preventive action database. Responsibility for
resolving the problem is assigned to a specific individual (“the recipient”).

2. The EMR, working with the recipient, determines an appropriate due date for resolving
the CAPAN.

B. Determining and Implementing Corrective and Preventive Actions

1. The CAPAN is issued to the recipient, who is responsible fo r investigation and

resolution of the problem. The recipient is also responsible for communicating the
corrective or preventive action taken.

2. If the recipient cannot resolve the problem by the specified due date, he/she is responsible
for determining an acceptable alternate due date with the EMR.

C. Tracking CAPAN’s

1. Close-out of CAPAN’s should be tracked by the EMR or his designee using Form 15-2
b.
CAPAN’ whose resolution dates are overdue appear on the Overdue Solutions report.
The EMR is responsible for issuing this report on a weekly basis to the Plant
Manager
and the recipients of any overdue CAPAN’s.

2. Records of CAPAN’s are maintained in the database for at least two years after
completion of the corrective or preventive action.

D. Tracking Effectiveness of Solutions

1. The recipient of a CAPAN, in conjunction with the requester, is responsible for verifying
the effectiveness of the solution. If the solution is deemed not effective, the CAPAN will
be reissued to the original recipient.

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 8
EMS Template
Revision 2.0 (March 2002)

Form 15-2a: Sample Corrective and Preventive Action Notice

Issue Date: Solution Due Date:

Requested by:
Issued to:

Problem Statement:

Most Likely Causes:

Suggested Solutions/Preventions:

Action Taken:

Measured Results:

Corrective and Preventive Action Closed by: Date:

Contact for Notice: Date completed:

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 9
 EMS Template
Revision 2.0 (March 2002)

Form 15-2b: Sample Corrective and Preventive Action Tracking Log

Corrective
and
Preventive
Plan Plan Action Effectiveness CAPAN
CAPAN Requested Due Completed Completed Verified Closed
Number By Issued To (Date) (Date) (Date) (Date) (Date)

JULIUS RONE
MD/CEO

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 10
EMS Template
Revision 2.0 (March 2002)

Form 15-2b: Sample Corrective and Preventive Action Tracking Log

EMS Corrective and Prevention Action, Management Review, and Continuous Improvement Module 15 - 11