John Lindberg, P.E., CIH

Senior EHS Consultant EnviroSense, Inc.

The Role of Corrective Action Process in EHS Program

Management

Corrective Action Processes in EHS Program Management

Origins of the terminology and concepts are in Quality Management Systems (QMS)

Definition: Process improvement to address non-conformities

through -

1. Root cause analysis

2. Plan development

3. Implementation

4. Verification

Sources for identifying non-conformities: 1. Notifications from customers/stakeholders

2. Internal/External audits

3. Process control deviations

4. Others

EHS examples of non-conformities:

1. Injuries/Spills

2. Lapsed training

3. Failure to identify and address regulatory requirements

4. Others

Corrective Action Plan Elements 1. Owner 2. Root Cause 3. Specific plan to correct and prevent recurrence 4. Target dates 5. Approval at next level of organization 6. Ranking of significance (major, minor, etc) 7. Verification

Root Cause Analysis Definition:

Systematic investigation resulting in –

1. Chain of causal factors

2. Conclusions supported by evidence

Getting to the Root Cause A variety of methods in practice -

1. 5 Whys

2. Ishikawa Diagrams

3. Others, 6M, 5S

5 Whys (easy to use)

State the problem

Within 5 iterations of asking “why?” - a root cause

(identifying system/process breakdown) is typically

identified

Corrective Action Plan Elements 1. Owner 2. Root Cause 3. Specific plan to correct and prevent recurrence 4. Target dates 5. Approval at next level of organization 6. Ranking of significance (major, minor, etc) 7. Verification

Verification of Effectiveness 1. Independent assessment of effective verification based on

evidence

2. Based on date stated in plan with consideration for sufficient time to accumulate evidence

3. Close plan and notify owner and approver of closure or proceed with escalation

Escalation Path 1. If verification demonstrates that the corrective action plan was

not implemented then the approving manager and next level of management should be notified.

2. This step should prompt a revision of the plan with the owner and line management to include review of root cause, plan, dates and additional resources as needed.

Corrective Action Plan Elements 1. Owner 2. Root Cause 3. Specific plan to correct and prevent recurrence 4. Target dates 5. Approval at next level of organization 6. Ranking of significance (major, minor, etc) 7. Verification

Systemic Implementation – How?

1. This depends on the capability of the organization

2. Ideally the EHS corrective action process will be integrated with an existing QMS process

3. Or – bootstrap approach – start wherever you are and forge ahead

4. Engage you H&S committee!

Practical Considerations 1. A corrective action process can be implemented with a simple

paper form

2. Or an electronic records process (spreadsheet)

3. Is best implemented with an electronic process that supports: assignment, creation, routing, approval, tracking, verification and escalation, recordkeeping

4. All of the methods involve some scheme for periodic review

Natural evolution of systematic EHS program management by starting with a Corrective Action Process

Establishment of resource priority (examples) Documentation management

Records management

Internal Audit

Identification of business and stakeholder requirements

The Stretch Goals

1. EHS Policy

2. Continuous improvement

3. Goal setting

4. Programs with measurable outcomes

5. 3rd party certification (VPP, OHSAS 18001, ISO14001)

6. And………….

Integration of EHS with the culture of your business organization!

You will be speaking the same language and employing the same methods used by everyone involved with product and service quality assurance and customer satisfaction

Thank you!

Questions?

Good Thinking !