Washington State Department of Ecology An Environmental Management System Alternative to Pollution Prevention Planning EMS – Monitoring & Measuring November 5, 2012 2012 -2013 Webinar Series Partners: National Pollution Prevention Roundtable Stewardship Action Council The Auditing Roundtable

2012 -2013 Webinar Series Overview Introduction to EMS – National Pollution Prevention Roundtable September 25, 2012 Introduction to Ecology’s EMS Program EMS Overview ISO14001 Gap Analysis Tool   Introduction to EMS – Part 2 National Pollution Prevention Roundtable October 16, 2012 Ecology’s EMS Program Toxics Reduction Overview Objectives & targets

2012 -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 & Engagement Ecology EMS Guidance

2012 -2013 Webinar Series Overview EMS Auditing Session I - The Auditing Roundtable (January/February 2013) Preparing for and Conducting EMS Audits Understanding EMS Auditing EMS Auditor Qualifications Pre-Audit Planning & Preparation Conducting the EMS Audit Ecology EMS Guidance EMS Auditing Session II - The Auditing Roundtable (March/April 2013) Audit Reporting, Evaluations and Management Review

Ecology EMS Alternative Provides flexible approach to P2 planning. Meets RCW 70.95C; Chapter 173-307 WAC requirements Work with Ecology to demonstrate operating EMS is in place.

EMS 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.

EMS 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 e-mail supporting materials to regional staff.

Ecology’s Pollution Prevention Criteria 2.1 Pollution Prevention Policy 2.2 Implementation 2.3 Monitoring & Measurement

DRAFT

DRAFT – EMS Checklist

Stewardship Action Council Environmental Management Systems Training (EMS): Monitoring and Measuring Presented by Stewardship Action Council Anne Vogel-Marr, Executive Director Charlotte Valentine, Program Manager

Content Introduction Review Operational Controls Characteristics of an EMS Basic Management System Framework Operational Controls Monitoring and Measuring

Stewardship Action Council Who we are Coalition of diverse stakeholders, including industry, state government, NGO community, social investment groups and academia What we do Drive and recognize sustainable performance though Webinars Sharing of ideas Creation of a learning network Promoting the accomplishments of our members Regional collaborative partnerships Design and implementation of a sustainability index

Your Role In EMS Employees should understand all elements of your 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. 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.

Purpose Why have an EMS? External drivers, as well as internal ones, dictate the need for an EMS program. Assist in maintaining compliance Drive continuous improvement Replace P2 Planning in the state of Washington

What happens when you do not have a system in place? Reactive response to problems Recurring problems Overwhelmed “specialists” Inability to capitalize on opportunities to improve environmental performance Reinventing the wheel; inefficiency. Changes can cause upsets and compliance problems Reactive response to problems A 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 performance Reinventing the wheel; inefficiency. Changes can cause upsets and compliance problems The 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.

How would you recognize an organization with a strong EMS? Consistent approach Continuous improvement Mistakes are caught before they become big problems Clear guidance Smooth adjustment to change Everyone understands their role Key persons can be absent and the system continues to operate well Management has tools to know performance status and to manage it

The 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: Plan Site Activities (Aspects) and Impacts Legal and Other Requirements Objectives and Targets Management of Change Implement Roles and Responsibilities Communication Design, Construction & Operational Controls Community Outreach & Stewardship Training, Awareness & Compliance Documentation & Record keeping Check, Correct & Prevent Monitor &Measure Corrective & Preventative Actions Self-Assessment Process Review Management Review Plan – 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.

4. Check, Correct & Prevent EMS Example Toolbox 1. Policy 2. Plan 2.1. Aspects &Environmental Impacts 2.1.1. Aspect/Impact Procedure 2.1.2. Sample A/ I Matrix 2.2. Legal & Other Regulations 2.2.1. Sample Compliance Calendar 2.2.2. Key Regulatory Dates List 2.2.3. Construction Air Schedule 2.2.4. Sample Compliance Matrix 2.2.5. SF6 Emission Reduction Partnership 2.3. Objectives & Targets 2.3.1. Sample Objective/Target Template 2.4. Management of Change 2.4.1. Sample MOC Program 3. Implement 3.1. Management Controls 3.4. Roles & Responsibilities 3.1.1. Sample Procedures 3.5. Training, Awareness & Competence 3.1.2. MSD PRO 3.5.1. Training Programs 3.1.3. Sample Plans 3.5.2. Sample Training Matrix 3.2. Contractor/Vendor Management Controls 3.6. Communication 3.6.1. Key Sample Letters 3.2.1. Waste Management Vendor Audit Program 3.7. Community Outreach & Stewardship 3.7.1. PLT Overview 3.3. Technical Operational Controls 3.8. Documentation & Recordkeeping 3.3.1. PS Support 3.3.2. Chemical Unloading Guidance 3.3.3. Chemical Preapproval Guidance 3.3.4. Vendor Spec’s for CEMS 4. Check, Correct & Prevent 4.1. Monitoring Management Processes 4.2. Incident Reporting & Investigation 4.2.1. Root Cause Guidance 4.3. EMS Self-Assessment 4.3.1. EMS Checklist 4.3.2. EMS Protocol 4.4. Corrective Actions 4.4.1. Non-conformance Tracking Template Review 5.1. Management Review 5.1.1. Management Review Agenda 5.1.2. Management Review Guidance EMS Overview EMS Expectation EMS How to Manual EMS Gap Analysis Checklist Reference Materials Plan – 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.

Process for Developing an EMS Understand EMS Expectations, Risks, Requirements Develop Procedures and Controls Provide Training Define Roles and Responsibilities Analyze Environmental Aspects Review Franchise Manual and Environmental Policy Define Procedure Format and Approval Process Determine Controls Needed Identify Training Needs Create Compliance Matrix Create Procedures and Controls Set Annual Training Schedule Emission Limit Define Records and Who Keeps Operating Practice Provide Training Create Compliance Calendar Recordkeeping Label and Sort Requirements by Type: Monitoring Create Management of Change Procedures Annual Review/Update Reporting Analyze Environmental Aspects Create Emergency Response Plan(s) Training If Change…Then Create Incident Investigation Procedure If Incident…Then Document Approach in SEMP

Implementing 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 objectives Establishing roles and responsibilities for controlling operations that could have an environmental impact Maintaining records and documents related to key operations (to document what has been done) Communicating important information to everyone in the organization Training employees Today we will talk about implementing controls, and how to monitor and measure their effectiveness. A later webinar will focus on Communications and Engagement.

Implementing 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 place Note where controls are missing and may be needed Note where controls may be inadequate

Identifying Controls for Operational Impacts D = Direct I = Indirect   Impact W = Water A = Air G = Groundwater S = Soil F = Fauna / Flora WST = Waste Burden NR = Natural Resources Depletion A/P A = Actual P = Potential Significance 1 = Minor 2 = Moderate 3 = Significant Likelihood 1 = Low 2 = Moderate 3 = Significant

Implementing Controls For controls that are missing or inadequate: Prioritize your efforts by starting with the most serious risk sources first If control is inadequate, improve it If control is missing and needed, implement it Do not over control Often the simple controls work best Talk to your employees Employees will know what is working and not working and are a great source of ideas for fixes Track the creation of the controls and follow through

Implementing 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. champion Your system is EVERY employees job Plan for change In personnel, operational requirements (a new process) and permitting requirements

Monitoring and Measuring Evaluate environmental performance Analyze root causes of problems Assess compliance with legal requirements Identify areas requiring corrective action Improve performance and increase efficiency BENEFITS

Monitoring and Measuring Information about things that are not working within the system comes from many sources, such as: Routine inspections/monitoring Facility “walk-around” Compliance audits EMS audits Regulatory agency inspections Accident investigations Critique after an emergency response drill Management review Compliance 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.

Monitoring and Measuring Getting Started Clearly 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

What should be monitored or measured? Operations with significant impacts Effectiveness of operational procedures Compliance with legal requirements Contractor activities Employee Roles and Responsibilities Document and recordkeeping practices Performance against targets and objectives Equipment Training effectiveness

Monitoring 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. Observe Compare the procedure to your observations Interview Talk to the person(s) responsible for conducting that operation to ensure s/he is familiar with and follows the procedures. Review Check related records to verify that the required actions are occurring (ties to Documents/ Recordkeeping)

Monitoring 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?

Monitoring 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?

Monitoring and Measuring Operational Procedures Common System Failures in Operational Procedures and Activities Compliance 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 wans Changes not caught

Monitoring and Measuring Contractor Activities Evaluating Contractor Activities: Observe a contractor executing a procedure driven activity Select a sample of contractors who have worked on site How were environmental requirements Incorporated 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.

Monitoring 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?

Monitoring and Measuring Contractor Activities Common System Failures in Contractor Selection and Use Environmental 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.

Monitoring 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)

Monitoring 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)

Monitoring 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.

Monitoring 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?

Monitoring and Measuring Documentation and Recordkeeping The Key Document to Have - The EMS Manual A “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 criteria While 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.

Monitoring and Measuring Documentation and Recordkeeping PURPOSE 3 SCOPE 3 OVERVIEW 3 1.0 Environmental Policy 4 1.1. Policy Statement 4 2.0 Plan 5 2.1. Aspects & Environmental Impacts 5 2.2. Legal & Other Requirements/Commitments 5 2.3. Objectives and Targets 6 2.4. Management of Change 8 3.0 Implement 8 3.1. Management Controls 8 3.2. Roles and Responsibilities 11 3.3. Training, Awareness, and Competence 11 3.4. Communication 12 3.5. Community Outreach and Stewardship 13 3.6. Documentation and Recordkeeping 13 4.0 Check, Correct, and Prevent 14 4.1. Monitoring and Measuring 15 4.2. Audit/Assessment Process 15 4.3. Corrective and Preventive Actions 15 5.0 Review 16 5.1. Environmental Management System Review 16 Corporate EMS Manual Corporate EMS Manual

Monitoring and Measuring Documentation and Recordkeeping APPENDIX A - Site Maps, Organization Chart, and Ownership Structure 11 APPENDIX B - Environmental Costs, Business/Operations Plan 12 APPENDIX C - List of Permits, Licenses, and Authorizations 13 APPENDIX D - Environmental Compliance Calendar, and References to Master List of Regulatory Required Reports and Submittals 14 APPENDIX E - Facility Environmental Inventories and Profiles 15 APPENDIX F - Aspect/Impact Identification and Procedure 16 APPENDIX G - List of Company EMS Policies, Guidance Documents, Procedures and Tools 17 APPENDIX H - Site Targets and Objectives 18 APPENDIX I - Self Assessment Checklist, Plan and Schedule and Audit Schedule 19 APPENDIX J - Environmental Incentive Goals 20 APPENDIX K - Incentive/Discipline Program 21 APPENDIX L - Stewardship Efforts 22 APPENDIX M - Training Matrix, Course Overview and Schedule 23 APPENDIX N - Regulatory Inspection Procedure 24 APPENDIX O - Response to Enforcement Actions 25 APPENDIX P - Regulatory Point of Contact List 26 Monitoring and Measuring Documentation and Recordkeeping RECORD OF CHANGES SUMMARY iii Plant Site Environmental Management Plan Approval iv 1.0 INTRODUCTION 1 1.1 Mission Statement 1 1.2 Management Organization and Responsibilities 2 1.3 ISO 14001 Overview (OPTIONAL) 2 2.0 FACILITY INFORMATION AND ENVIRONMENTAL RESOURCES 3 2.1 Facility Description and Environmental Characteristics 3 2.2 Site-Level Business and Operating Plans (current year) 3 3.0 ENVIRONMENTAL COMMITMENTS 5 3.1 Permitting Process 5 3.2 Major Permits, Licenses, Authorizations, and Commitments 5 3.3 Regulatory Tracking 5 4.0 ENVIRONMENTAL MANAGEMENT SYSTEM (EMS) 6 4.1 Overview 6 4.2 Aspects/Impacts 6 4.3 Site-level Procedures 7 4.4 EMS Targets/Objectives 7 4.5 Self-Assessment Program and Schedule 7 4.6 Additional EMS Components 7 5.0 ENVIRONMENTAL EXCELLENCE 8 5.1 Annual Environmental Incentive Goals 8 5.2 Pollution Prevention (P2) Goals 8 5.3 Incentives/Discipline 8 5.4 Environmental Stewardship 8 6.0 TRAINING AND COMMUNICATION 8 6.1 Training 8 6.1.1 Mandated Compliance Training 8 6.1.2 Site Environmental Awareness Training 9 6.2 Communicating Onsite 9 6.3 Communicating Externally 9 7.0 INSPECTIONS AND ENFORCEMENT 9 7.1 Regulatory Inspections 9 7.2 Response to Environmental Enforcement Actions 9 7.3 Regulatory Point of Contact List 10 7.4 Emergency Response (ICP) 10 8.0 ADMINISTRATION AND RECORDKEEPING 10 8.1 Training Records 10 8.2 Document Management 10 8.3 SEMP Administration 10 8.4 Management Review 10 Table of Contents (continued) Facility EMS Manual APPENDIX A Site Maps, Organization Chart, and Ownership Structure 11 APPENDIX B Environmental Costs, Business/Operations Plan 12 APPENDIX C List of Permits, Licenses, and Authorizations 13 APPENDIX D Environmental Compliance Calendar, and References to Master List of Regulatory Required Reports and Submittals 14 APPENDIX E Facility Environmental Inventories and Profiles 15 APPENDIX F Aspect/Impact Identification and Procedure 16 APPENDIX G List of Company EMS Policies, Guidance Documents, Procedures and Tools 17 APPENDIX H Site Targets and Objectives 18 APPENDIX I Self Assessment Checklist, Plan and Schedule and Audit Schedule 19 APPENDIX J Environmental Incentive Goals 20 APPENDIX K Incentive/Discipline Program 21 APPENDIX L Stewardship Efforts 22 APPENDIX M Training Matrix, Course Overview and Schedule 23 APPENDIX N Regulatory Inspection Procedure 24 APPENDIX O Response to Enforcement Actions 25 APPENDIX P Regulatory Point of Contact List 26 Facility EMS Manuel

Monitoring and Measuring Documentation and Recordkeeping Other EMS Documentation Your Policy Your environmental policy Your organizational structure and key responsibilities a description or summary of how your organization satisfies EMS requirements How 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 instructions Other 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.

Monitoring 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: Legible Dated (with dates of revision) Readily identifiable Maintained in an orderly manner Retained for a period specified in the document control procedure Updated, 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 made Training required? Completed?

Monitoring 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 legible Traceable 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

Monitoring 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 requirements Reports of identified nonconformities, corrective action plans and corrective action tracking data Results of environmental aspects identification Reports of progress towards meeting objectives and targets Hazardous material spill / other incident reports Communications with customers, suppliers, contractors and other external parties Permits, licenses and other approvals Job descriptions and performance evaluations Results of management reviews Training records Sampling and monitoring data Inspection records Maintenance records EMS audit and regulatory compliance audit reports Equipment calibration records

Monitoring 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.

Monitoring and Measuring Evaluation Best Practices DO Spot check problem areas more frequently Involve folks familiar with the area and activities Watch activities involving contractors Annual System Review Develop and use a self-assessment tool DON’T Notify others when you will be observing Limit employee observations to just new-hires

Self-Assessment Working Tool Documents to Review Documents for Review SEMP Current, updated Management review meeting minutes and action plan Followed up and implemented Inventories Current? Training records How do they update training requirements? Verify required training is occurring – pick several List of major changes in last year Beth’s list of required regulation cross checked against CC Follow to see if feed into system T/O progress records Has CC been updated? MMS populated? Management of change procedure Verify T/O are being implemented Purchasing procedures/records Are all changes included? Is it implemented? Ash mgmt. procedure/coal handling procedure Review for environmental implications and management Pond cleaning procedure Compare to operation in field Chemical unloading procedure Compare to records for process verification Monitoring procedures Calibration procedures Inspection logs Compare to actual implementation Contractor mgmt. procedure/or get overview of process Review to ensure complete Emergency call list Verify process being managed per management review action item Root cause for spill, changes recorded and evidence that changes implemented Is it current? Is process working? Chemical pre-approval procedure and documentation Most recent material brought onsite and associate MSDS Verify environmental review occurred, required MSDS onsite P2 program documentation Verify program implemented All appendices in SEMP Current/updated Training materials Complete/accurate/current Incoming call log book Verify records being maintained Contractor records, pre-approval, chemicals used, MSDSs, environmental review, etc. Contractor management review Compare to requirement Tank inspection records Is compliance evaluation conducted? Compliance evaluation documentation Complete, current, functional? Nonconformance tracking sheet

Corrective Action Process Check, Correct, Prevent Corrective 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 Process Identify problems and/or issues Analyze to determine corrective and preventive actions Assign responsibility for fixing the problem Allocate resources Track progress to ensure actions are taken and that the action is effective Update documented procedures and programs as needed The 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.

Check, Correct, Prevent Maintain a Corrective Action Log that identifies: Who, What, When, How Corrective Action and Preventative Action Target date for completion for each Responsible individual for each What procedures, training or documentation needs to be updated Who is responsible for the update When it must be completed by

Stewardship Action Council Contact Information Anne Vogel-Marr, Executive Director anne@stewardshipaction.org (301)482-2523 Charlotte Valentine, Program Manager charlotte@stewardshipaction.org (202)296-3952 Stewardship Action Council 1155 15th Street NW, Suite 500, Washington, DC 20005 www.stewardshipaction.org