Presentation on theme: "Washington State Department of Ecology"— Presentation transcript:
1Washington State Department of Ecology An Environmental Management System Alternative toPollution Prevention PlanningEMS – Monitoring & MeasuringNovember 5, 2012Webinar Series Partners:National Pollution Prevention RoundtableStewardship Action CouncilThe Auditing Roundtable
22012 -2013 Webinar Series Overview Introduction to EMS – National Pollution Prevention RoundtableSeptember 25, 2012Introduction to Ecology’s EMS ProgramEMS OverviewISO14001 Gap Analysis ToolIntroduction to EMS – Part 2 National Pollution Prevention RoundtableOctober 16, 2012Ecology’s EMS ProgramToxics Reduction OverviewObjectives & targets
32012 -2013 Webinar Series Overview EMS Implementation Part I – Stewardship Action Council (November 5, 2012)Monitoring & Measurement EMS Implementation Part II – Stewardship Action Council (December 4, 2012)Communications & EngagementEcology EMS Guidance
42012 -2013 Webinar Series Overview EMS Auditing Session I - The Auditing Roundtable (January/February 2013)Preparing for and Conducting EMS AuditsUnderstanding EMS AuditingEMS Auditor QualificationsPre-Audit Planning & PreparationConducting the EMS AuditEcology EMS GuidanceEMS Auditing Session II - The Auditing Roundtable (March/April 2013)Audit Reporting, Evaluations and Management Review
5Ecology EMS Alternative Provides flexible approach to P2 planning.Meets RCW 70.95C; Chapter WAC requirementsWork with Ecology to demonstrate operating EMS is in place.
6EMS Alternative Process Work with regional Ecology staff at earliest opportunity.Submit request describing how EMS meets P2 planning criteria.Submit EMS documentation for regional staff review & collaboration.
7EMS Alternative Process Host an Ecology EMS Site Visit.Conduct Facility Periodic Assessment (at least once every five years – 3 years recommended.Submit annual progress report via TurboPlan or supporting materials to regional staff.
11Stewardship Action Council Environmental Management Systems Training (EMS): Monitoring and MeasuringPresented byStewardship Action CouncilAnne Vogel-Marr, Executive DirectorCharlotte Valentine, Program Manager
12Content Introduction Review Operational Controls Characteristics of an EMSBasic Management System FrameworkOperational ControlsMonitoring and Measuring
13Stewardship Action Council Who we areCoalition of diverse stakeholders, including industry, state government, NGO community, social investment groups and academiaWhat we doDrive and recognize sustainable performance thoughWebinarsSharing of ideasCreation of a learning networkPromoting the accomplishments of our membersRegional collaborative partnershipsDesign and implementation of a sustainability index
14Your Role In EMSEmployees should understand all elements of your system and how they work togetherEach part of the EMS system is dependent upon the other parts functioning as intended.Failure of one part of the system can result in failure of the system as a whole.The role each person plays is absolutely critical.While you are probably well aware of the pieces of the system in which you have a role, it is important that each employee understand all elements of this system and how they work together. Each part of the EMS system is dependent upon the other parts functioning as intended. Failure of one part of the system can result in failure of the system as a whole. Therefore, the role each person plays is absolutely critical. Every employee in your organization makes a difference.
15PurposeWhy have an EMS?External drivers, as well as internal ones, dictate the need for an EMS program.Assist in maintaining complianceDrive continuous improvementReplace P2 Planning in the state of Washington
16What happens when you do not have a system in place? Reactive response to problemsRecurring problemsOverwhelmed “specialists”Inability to capitalize on opportunities to improve environmental performanceReinventing the wheel; inefficiency.Changes can cause upsets and compliance problemsReactive response to problemsA facility makes a change to process equipment and learns after the equipment is installed that it needed a permit.Recurring problems -A compliance audit finds a problem with the wrong labels on waste drums. The problem is fixed, but it happens again a few months later.Overwhelmed “specialists.”Potential for unidentified risks and surprises - Environmental permits are not obtained for activities during an outage; the schedule gets delayed, causing added expense and inconvenience.Inability to capitalize on opportunities to improve environmental performanceReinventing the wheel; inefficiency.Changes can cause upsets and compliance problemsThe environmental manager wins the lottery and skips town, and compliance problems arise quickly.Problems such as these can be fixed, but without a system in place, they will likely reoccur again and again.
17How would you recognize an organization with a strong EMS? Consistent approachContinuous improvementMistakes are caught before they become big problemsClear guidanceSmooth adjustment to changeEveryone understands their roleKey persons can be absent and the system continues to operate wellManagement has tools to know performance status and to manage it
18The Four Elements of an EMS: Cycle for Continuous Improvement Management systems are similar whether you are managing environmental issues, finance concerns, safety, or any other business issue.In addition to the policy, they consist of four critical elements:PlanSite Activities (Aspects) and ImpactsLegal and Other RequirementsObjectives and TargetsManagement of ChangeImplementRoles and ResponsibilitiesCommunicationDesign, Construction & Operational ControlsCommunity Outreach & StewardshipTraining, Awareness & ComplianceDocumentation & Record keepingCheck, Correct & PreventMonitor &MeasureCorrective & Preventative ActionsSelf-Assessment ProcessReviewManagement ReviewPlan – identify risks and impacts. In other words, think about the effects our activities may have, and set goals to reduce them.Implement – actions taken to control risks and impacts (procedures, checklists, training, reporting, documentation, etc.)Check, Correct, and Prevent – make sure that what needs to be done is actually getting done (measuring to make sure we meet our emissions limits, reviewing records, conducting audits)Review – step back and look at the whole system to see if it is working.
194. Check, Correct & Prevent EMS Example Toolbox1. Policy2. Plan2.1. Aspects &Environmental ImpactsAspect/Impact ProcedureSample A/ I Matrix2.2. Legal & Other RegulationsSample Compliance CalendarKey Regulatory Dates ListConstruction Air ScheduleSample Compliance MatrixSF6 Emission Reduction Partnership2.3. Objectives & TargetsSample Objective/Target Template2.4. Management of ChangeSample MOC Program3. Implement3.1. Management Controls3.4. Roles & ResponsibilitiesSample Procedures3.5. Training, Awareness & CompetenceMSD PROTraining ProgramsSample PlansSample Training Matrix3.2. Contractor/Vendor Management Controls3.6. CommunicationKey Sample LettersWaste Management Vendor Audit Program3.7. Community Outreach & StewardshipPLT Overview3.3. Technical Operational Controls3.8. Documentation & RecordkeepingPS SupportChemical Unloading GuidanceChemical Preapproval GuidanceVendor Spec’s for CEMS4. Check, Correct & Prevent4.1. Monitoring Management Processes4.2. Incident Reporting & InvestigationRoot Cause Guidance4.3. EMS Self-AssessmentEMS ChecklistEMS Protocol4.4. Corrective ActionsNon-conformance Tracking TemplateReview5.1. Management ReviewManagement Review AgendaManagement Review GuidanceEMS OverviewEMS ExpectationEMS How to ManualEMS Gap Analysis ChecklistReference MaterialsPlan – identify risks and impacts. In other words, think about the effects our activities may have, and set goals to reduce them.Implement – actions taken to control risks and impacts (procedures, checklists, training, reporting, documentation, etc.)Check, Correct, and Prevent – make sure that what needs to be done is actually getting done (measuring to make sure we meet our emissions limits, reviewing records, conducting audits)Review – step back and look at the whole system to see if it is working.
20Process for Developing an EMS Understand EMS Expectations, Risks, RequirementsDevelop Procedures and ControlsProvide TrainingDefine Roles and ResponsibilitiesAnalyze Environmental AspectsReview Franchise Manual and Environmental PolicyDefine Procedure Format and Approval ProcessDetermine Controls NeededIdentify Training NeedsCreate Compliance MatrixCreate Procedures and ControlsSet Annual Training ScheduleEmission LimitDefine Records and Who KeepsOperating PracticeProvide TrainingCreate Compliance CalendarRecordkeepingLabel and Sort Requirements by Type:MonitoringCreate Management of Change ProceduresAnnual Review/UpdateReportingAnalyze Environmental AspectsCreate Emergency Response Plan(s)TrainingIf Change…ThenCreate Incident Investigation ProcedureIf Incident…ThenDocument Approach in SEMP
21Implementing and Monitoring Controls “How We Do What We Do”Implementing Controls - operational controls we use for maintaining compliance, minimizing risks, and achieving our goals.Examples include:Implementing programs and procedures to maintain compliance, reduce risk, and reach performance objectivesEstablishing roles and responsibilities for controlling operations that could have an environmental impactMaintaining records and documents related to key operations (to document what has been done)Communicating important information to everyone in the organizationTraining employeesToday we will talk about implementing controls, and how to monitor and measure their effectiveness. A later webinar will focus on Communications and Engagement.
22Implementing Controls Identify risks (A/I Assessment)For each risk, determine:Control or influence?What would be impacted?Seriousness of impact?Likelihood of impact?For each risk, identify the controls you have in placeNote where controls are missing and may be neededNote where controls may be inadequate
23Identifying Controls for Operational Impacts D = DirectI = IndirectImpactW = Water A = AirG = Groundwater S = SoilF = Fauna / FloraWST = Waste BurdenNR = Natural Resources DepletionA/PA = ActualP = PotentialSignificance 1 = Minor 2 = Moderate 3 = SignificantLikelihood1 = Low2 = Moderate3 = Significant
24Implementing Controls For controls that are missing or inadequate:Prioritize your efforts by starting with the most serious risk sources firstIf control is inadequate, improve itIf control is missing and needed, implement itDo not over controlOften the simple controls work bestTalk to your employeesEmployees will know what is working and not working and are a great source of ideas for fixesTrack the creation of the controls and follow through
25Implementing Controls Questions to consider when implementing controls:How are we going to ensure this task is accomplished?Do we need records validated completion?How will you manage your documents?How to ensure they are current, legible, accessible, etc.?How long should records be kept?Have we adequately communicated our expectations to the responsible individuals?Have roles and responsibilities been adequately defined?Who should be responsible to complete this task?Are they trained?Do they have the resources necessary?Is there a back up if they are unavailable?Hero vs. championYour system is EVERY employees jobPlan for changeIn personnel, operational requirements (a new process) and permitting requirements
26Monitoring and Measuring Evaluate environmental performanceAnalyze root causes of problemsAssess compliance with legal requirementsIdentify areas requiring corrective actionImprove performance and increase efficiencyBENEFITS
27Monitoring and Measuring Information about things that are not working within the system comes from many sources, such as:Routine inspections/monitoringFacility “walk-around”Compliance auditsEMS auditsRegulatory agency inspectionsAccident investigationsCritique after an emergency response drillManagement reviewCompliance audits, EMS audits, regulatory inspections, and accident investigations all generate their own findings which you can use to strengthen your system. Now, let’s focus on how you can monitor your system internally.
28Monitoring and Measuring Getting StartedClearly define your needs.While collecting meaningful information is clearly important, resist the urge to collect data “for data’s sake.”Start with a relatively simple monitoring and measurement process, then build on it as you gain experience with your EMS.Step 1
29What should be monitored or measured? Operations with significant impactsEffectiveness of operational proceduresCompliance with legal requirementsContractor activitiesEmployee Roles and ResponsibilitiesDocument and recordkeeping practicesPerformance against targets and objectivesEquipmentTraining effectiveness
30Monitoring and Measuring Operational Procedures Evaluating the System:Sample procedures to verify effective implementation. Start with most critical. Look for periods where changes occur in routine, e.g. responsible individuals sick, on vacation, etc.ObserveCompare the procedure to your observationsInterviewTalk to the person(s) responsible for conducting that operation to ensure s/he is familiar with and follows the procedures.ReviewCheck related records to verify that the required actions are occurring (ties to Documents/ Recordkeeping)
31Monitoring and Measuring Operational Procedures Key questions to consider when evaluating the system:What procedures/controls are needed to manage and minimize significant environmental impacts of activities, including those not regulated (e.g., energy use, solid waste generation or recycling)?What procedures or programs have already been established to control and manage environmental aspects with associated impacts?When a procedure is not implemented as required, what is the root cause (e.g., delegation of authority, training, activity conducted but not recorded)?Based on the cause, what system-based resolutions is require to prevent re-occurrence?
32Monitoring and Measuring Operational Procedures Questions to consider when operational activities are conducted without procedures:Is there a consistent understanding of how things are supposed to work?Are there other “checks and balances” in place, such as training, checklists, routine inspections that confirm it is occurring?Does evidence show that the activity is occurring consistently, i.e, is there a performance problem?If a key responsible person won the lottery and skipped town, would the system continue to function?
33Monitoring and Measuring Operational Procedures Common System Failures in Operational Procedures and ActivitiesCompliance requirements have not been translated into clear guidance for operators so much of the knowledge is in the head of one or two people.Systems are not in place to ensure consistent reporting to regulatory agencies so reports are filed late, notifications are not made when there are releases, etc.Procedures exist but they are not current and are not used by employees in practice.Routine verification is not conducted, so adherence to procedures wansChanges not caught
34Monitoring and Measuring Contractor Activities Evaluating Contractor Activities:Observe a contractor executing a procedure driven activitySelect a sample of contractors who have worked on siteHow were environmental requirementsIncorporated into the contract?Communicated to contractors?How is performance evaluated?Interview employees and review incident logs to verify if there have been any incidents where contractors are not following environmental requirements. Research these incidents to understand the root cause.
35Monitoring and Measuring Contractor Activities Questions to consider:How do you ensure that vendors are complying with environmental contract requirements and certifications (examples of vendors: chemical suppliers, waste management service providers, and labs)?How do you communicate environmental expectations to contractors/vendors working on site?
36Monitoring and Measuring Contractor Activities Common System Failures in Contractor Selection and UseEnvironmental risks are not routinely considered during contractor selection.Environmental expectations of contractors are not communicated to contractors.Responsibilities for overseeing contractors working on site are not well defined or managed.
37Monitoring and Measuring Employee Roles and Responsibilities Determine if key individuals have designated backups for their responsibilities, and if these individuals are knowledgeable of this designation and familiar with the requirements to complete it.Have people received proper training in the areas for which they have responsibility?If there is a performance problem, is it due to confusion about who was responsible?(Potentially ties to Training and Awareness, Operational Control, Monitoring and Measurement)
38Monitoring and Measuring Employee Roles and Responsibilities Questions to Consider:Are roles and responsibilities of key staff on site who manage environmental issues clearly defined?Are designated backups assigned?How are people made aware of their responsibilities?How are individuals held accountable for carrying out their assigned responsibilities, e.g., performance reviews, consequences/rewards based on performance?What roles do the management team play in reinforcing the importance of environmental management?Are resources (people required, specialized skills, technology, or financial) adequate?Has a management representative been designated with responsibility to oversee implementation of the EMS and report on progress to top management?3. How are people made aware of their responsibilities? (ties to Training and Awareness)7. Has a management representative been designated with responsibility to oversee implementation of the EMS and report on progress to top management? (tie to Management Review)
39Monitoring and Measuring Employee Roles and Responsibilities Common System Failures in Employee Roles and Responsibilities:Roles and responsibilities have not been clearly defined and/or documented.One key person is responsible for many environmental activities and no backup for them is designated.Responsibilities are defined but people are not held accountable for carrying them out.Non-management personnel have been assigned management responsibilities, but lack authority required, e.g., cannot budget resources or do not have the organizational clout to affect action.Resources required to perform specific tasks required to implement the EMS have not been provided.
40Monitoring and Measuring Documentation and Recordkeeping Questions to Consider:How are documents created, reviewed for approval, and kept current?What is the procedure for creation, review, and maintenance?What determines the frequency of the review and revisions?How do you ensure that the most current version of environmental documents, such as procedures, are available to those who may need to reference them?Are obsolete documents that are retained for legal and/or knowledge preservation purposes identified?Who has responsibility for maintaining environmental records? Is there a back-up?How do you ensure that you keep records for the retention times required by regulations or company policy?
41Monitoring and Measuring Documentation and Recordkeeping The Key Document to Have - The EMS ManualA “road map” or description that summarizes how the pieces of the EMS fit together. This roadmap generally takes the form of an EMS manual.Explains how your organization implements the EMS criteriaWhile you don’t need to maintain a single “manual” that contains all of your EMS documentation, you should maintain a summary of the EMS that:• Describes the system’s core elements (and how the elements relate to each other), and• Provides direction to related documentation.
42Monitoring and Measuring Documentation and Recordkeeping PURPOSE 3SCOPE 3OVERVIEW 31.0 Environmental Policy 41.1. Policy Statement 42.0 Plan 52.1. Aspects & Environmental Impacts 52.2. Legal & Other Requirements/Commitments 52.3. Objectives and Targets 62.4. Management of Change 83.0 Implement 83.1. Management Controls 83.2. Roles and Responsibilities 113.3. Training, Awareness, and Competence 113.4. Communication 123.5. Community Outreach and Stewardship 133.6. Documentation and Recordkeeping 134.0 Check, Correct, and Prevent 144.1. Monitoring and Measuring 154.2. Audit/Assessment Process 154.3. Corrective and Preventive Actions 155.0 Review 165.1. Environmental Management System Review 16Corporate EMS ManualCorporate EMS Manual
43Monitoring and Measuring Documentation and Recordkeeping APPENDIX A - Site Maps, Organization Chart, and Ownership Structure11APPENDIX B - Environmental Costs, Business/Operations Plan12APPENDIX C - List of Permits, Licenses, and Authorizations13APPENDIX D - Environmental Compliance Calendar, and References to Master List of Regulatory Required Reports and Submittals14APPENDIX E - Facility Environmental Inventories and Profiles15APPENDIX F - Aspect/Impact Identification and Procedure16APPENDIX G - List of Company EMS Policies, Guidance Documents, Procedures and Tools17APPENDIX H - Site Targets and Objectives18APPENDIX I - Self Assessment Checklist, Plan and Schedule and Audit Schedule19APPENDIX J - Environmental Incentive Goals20APPENDIX K - Incentive/Discipline Program21APPENDIX L - Stewardship Efforts22APPENDIX M - Training Matrix, Course Overview and Schedule23APPENDIX N - Regulatory Inspection Procedure24APPENDIX O - Response to Enforcement Actions25APPENDIX P - Regulatory Point of Contact List26Monitoring and MeasuringDocumentation and RecordkeepingRECORD OF CHANGES SUMMARY iiiPlant Site Environmental Management Plan Approval iv1.0 INTRODUCTION 11.1 Mission Statement 11.2 Management Organization and Responsibilities 21.3 ISO Overview (OPTIONAL) 22.0 FACILITY INFORMATION AND ENVIRONMENTAL RESOURCES 32.1 Facility Description and Environmental Characteristics 32.2 Site-Level Business and Operating Plans (current year) 33.0 ENVIRONMENTAL COMMITMENTS 53.1 Permitting Process 53.2 Major Permits, Licenses, Authorizations, and Commitments 53.3 Regulatory Tracking 54.0 ENVIRONMENTAL MANAGEMENT SYSTEM (EMS) 64.1 Overview 64.2 Aspects/Impacts 64.3 Site-level Procedures 74.4 EMS Targets/Objectives 74.5 Self-Assessment Program and Schedule 74.6 Additional EMS Components 75.0 ENVIRONMENTAL EXCELLENCE 85.1 Annual Environmental Incentive Goals 85.2 Pollution Prevention (P2) Goals 85.3 Incentives/Discipline 85.4 Environmental Stewardship 86.0 TRAINING AND COMMUNICATION 86.1 Training 8Mandated Compliance Training 8Site Environmental Awareness Training 96.2 Communicating Onsite 96.3 Communicating Externally 97.0 INSPECTIONS AND ENFORCEMENT 97.1 Regulatory Inspections 97.2 Response to Environmental Enforcement Actions 97.3 Regulatory Point of Contact List Emergency Response (ICP) ADMINISTRATION AND RECORDKEEPING Training Records Document Management SEMP Administration Management Review 10 Table of Contents (continued)Facility EMS ManualAPPENDIX ASite Maps, Organization Chart, and Ownership Structure11APPENDIX BEnvironmental Costs, Business/Operations Plan12APPENDIX CList of Permits, Licenses, and Authorizations13APPENDIX DEnvironmental Compliance Calendar, and References to Master List of Regulatory Required Reports and Submittals14APPENDIX EFacility Environmental Inventories and Profiles15APPENDIX FAspect/Impact Identification and Procedure16APPENDIX GList of Company EMS Policies, Guidance Documents, Procedures and Tools17APPENDIX HSite Targets and Objectives18APPENDIX ISelf Assessment Checklist, Plan and Schedule and Audit Schedule19APPENDIX JEnvironmental Incentive Goals20APPENDIX KIncentive/Discipline Program21APPENDIX LStewardship Efforts22APPENDIX MTraining Matrix, Course Overview and Schedule23APPENDIX NRegulatory Inspection Procedure24APPENDIX OResponse to Enforcement Actions25APPENDIX PRegulatory Point of Contact List26Facility EMS Manuel
44Monitoring and Measuring Documentation and Recordkeeping Other EMS DocumentationYour PolicyYour environmental policyYour organizational structure and key responsibilities a description or summary of how your organization satisfies EMS requirementsHow do we identify environmental aspects?How do we control documents?How do we comply with legal requirements?System-level procedures (e.g., procedure for corrective action)Activity or process-specific procedures / work instructionsOther important documents such as emergency response plans, training plans, etc.)EMS documentation describes what your system consists of (i.e., what you do and how you do it), while EMS records demonstrate that you are doing what the documentation said you would do.
45Monitoring and Measuring Documentation and Recordkeeping Evaluation of Documentation:Look for evidence of current versions of documents, e.g., are there outdated emergency plans in control rooms?Review a sample of various EMS documents and determine if they are:LegibleDated (with dates of revision)Readily identifiableMaintained in an orderly mannerRetained for a period specified in the document control procedureUpdated, as appropriate, based on changes to the facility, or corrective action feedback.Identify a recent change that would have required a change to a document such as a procedure and see if it was madeTraining required? Completed?
46Monitoring and Measuring Documentation and Recordkeeping Evaluation of Recordkeeping:Collect sample data and records of key systems for which records should be maintained and determine if:Records are legibleTraceable to an activity?Retrievable?Protected against damage or loss?Retention times established?Are changes reflected?Check to see if Training Records for key individuals with EMS responsibilities demonstrate consistency against training provided.ties to Training and Awareness
47Monitoring and Measuring Documentation and Recordkeeping What Records Should You Have? EMS documentation is related to (but not the same as) EMS records. EMS records demonstrate that you are doing what the documentation said you would do. Key Records to keep include, but are not limited to:Legal, regulatory and other code requirementsReports of identified nonconformities, corrective action plans and corrective action tracking dataResults of environmental aspects identificationReports of progress towards meeting objectives and targetsHazardous material spill / other incident reportsCommunications with customers, suppliers, contractors and other external partiesPermits, licenses and other approvalsJob descriptions and performance evaluationsResults of management reviewsTraining recordsSampling and monitoring dataInspection recordsMaintenance recordsEMS audit and regulatory compliance audit reportsEquipment calibration records
48Monitoring and Measuring Documentation and Recordkeeping Common System Failures in Documentation and Recordkeeping:Obsolete documents are not removed from use in operational areas.Documents are not routinely reviewed, revised, and approved for adequacy by authorized personnel, such as approval sign-offs, dates, and revision numbers.Record retention times are not defined and/or there is not a formal process to ensure they are maintained for the length of time required.Records are not maintained in an orderly and identifiable manner, for example, if a key person is out the day of a regulatory inspection, others could not locate key records.Records do not provide traceability to the activity the record is intended to document.
49Monitoring and Measuring Evaluation Best Practices DOSpot check problem areas more frequentlyInvolve folks familiar with the area and activitiesWatch activities involving contractorsAnnual System ReviewDevelop and use a self-assessment toolDON’TNotify others when you will be observingLimit employee observations to just new-hires
50Self-Assessment Working Tool Documents to ReviewDocuments for ReviewSEMPCurrent, updatedManagement review meeting minutes and action planFollowed up and implementedInventoriesCurrent?Training recordsHow do they update training requirements? Verify required training is occurring – pick severalList of major changes in last yearBeth’s list of required regulation cross checked against CCFollow to see if feed into systemT/O progress recordsHas CC been updated? MMS populated?Management of change procedureVerify T/O are being implementedPurchasing procedures/recordsAre all changes included? Is it implemented?Ash mgmt. procedure/coal handling procedureReview for environmental implications and managementPond cleaning procedureCompare to operation in fieldChemical unloading procedureCompare to records for process verificationMonitoring proceduresCalibration proceduresInspection logsCompare to actual implementationContractor mgmt. procedure/or get overview of processReview to ensure completeEmergency call listVerify process being managed per management review action itemRoot cause for spill, changes recorded and evidence that changes implementedIs it current?Is process working?Chemical pre-approval procedure and documentationMost recent material brought onsite and associate MSDSVerify environmental review occurred, required MSDS onsiteP2 program documentationVerify program implementedAll appendices in SEMPCurrent/updatedTraining materialsComplete/accurate/currentIncoming call log bookVerify records being maintainedContractor records, pre-approval, chemicals used, MSDSs, environmental review, etc.Contractor management reviewCompare to requirementTank inspection recordsIs compliance evaluation conducted?Compliance evaluation documentationComplete, current, functional?Nonconformance tracking sheet
51Corrective Action Process Check, Correct, PreventCorrective Action: The change implemented to resolve an identified problem. This change should include preventative measures.*The fix and follow-up should be appropriate to the nature and scale of the problem.Corrective Action ProcessIdentify problems and/or issuesAnalyze to determine corrective and preventive actionsAssign responsibility for fixing the problemAllocate resourcesTrack progress to ensure actions are taken and that the action is effectiveUpdate documented procedures and programs as neededThe records you keep, monitoring data you collect, and self-assessments you conduct help to show you areas that need improvement. In an EMS, corrective action does not involve just fixing the problem, but also investigating to the root cause of the problem. This helps ensure that a preventive action is implemented as well. For example, if labels are not put on drums, the root cause may indicate the need for a new procedure, or more training. It may indicate that a designated individual has not been identified to “back-up” the person usually performing this task when they are unable to do so. Audits and assessments are also performed to provide independent evidence that the program is working as planned.
52Check, Correct, PreventMaintain a Corrective Action Log that identifies:Who, What, When, HowCorrective Action and Preventative ActionTarget date for completion for eachResponsible individual for eachWhat procedures, training or documentation needs to be updatedWho is responsible for the updateWhen it must be completed by
53Stewardship Action Council Contact InformationAnne Vogel-Marr, Executive Director(301)Charlotte Valentine, Program Manager(202)Stewardship Action Councilth Street NW, Suite 500, Washington, DC