IGD 1015: Nonconformity, Corrective Action and Preventive Action

1.0

PURPOSE

 

 

 

This Interpretive Guidance Document (IGD) establishes responsibility and authority for identifying, handling, and investigating nonconformances and potential nonconformances, mitigating resulting impacts, and initiating and completing corrective and preventive action, including results and effectiveness of corrective action. It applies to all of our employees and those working on our behalf.

 

2.0

PROCESS

 

 

 

 

 

2.1

Responsibility and Authority

 

 

 

 

The Environmental, Safety, and Occupational Health (ESOH) Management Representative (EMR) has the primary responsibility and authority to monitor the ESOH Management System (ESOHMS) and is authorized to take necessary actions to resolve identified nonconformance issues and assist the Depot manager. The EMR functions as the Corrective Action Coordinator (CAC). The primary responsibilities of Depot managers and action officers are defined in IGD 1006 and include investigating findings, implementing corrective and preventive actions, and maintaining documentation.

 

 

 

 

 

2.2

Identifying Nonconformance or Potential Nonconformance

 

 

 

 

Nonconformance and corrective actions are identified via inputs such as internal and external compliance, conformance, and safety audits, program reviews, and other miscellaneous reports. Any corrective or preventive action taken to eliminate the causes of actual and potential nonconformance will be appropriate for the magnitude of problems and commensurate with the environmental, safety, and health impact encountered.

 

 

 

 

2.2.1

Inputs

 

 

Figure 1 outlines the flow of the corrective action process for internal self audits.

 

 

 

 

 

Figure 1

 

 

 

Corrective Action Process

 

 

Corrective Action Process

 

 

 

 

 

The EMR/CAC receives the reports, creates a list of findings (Corrective Action Summary Report [CASR]), and assigns Action Officers. The CASR will be in spreadsheet form and include columns for location (storage site or headquarters [HQ]), finding, recommended corrective action, root cause, action officer assigned to the corrective and preventive action(s), current status and completion date, audit report name, auditor name, and audit date.

 

 

The EMR/CAC will upload copies of the updated CASR To the agencies Q:drive at  DNSC-M : 1DNSC ME Corrective Action Summary Reports.

 

 

2.2.2

External Audits

 

 

 

 

 

Findings, from external parties such as regulators or auditors, regarding regulatory matters (warnings, notices of violations, etc.) must be addressed immediately. Upon receipt of the findings, the Depot managers must work with the EMR/CAC to identify the appropriate corrective and preventive action. Depending on the severity and/or complexity of the finding, a root cause analysis may be required (See 2.3.1, below).

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2.2.3

Releases

 

 

 

 

 

Releases related to ESOH must be reported by the Depot managers to the EMR immediately. The EMR will take the following actions:

  • Notify DLA Installation Support Environmental Management (DES-E) and the Office of General Counsel of any notice of violation, notice of noncompliance, warning letter, warning notice, deficient inspection report, consent order, or similar written notification from environmental regulatory authorities within 24 hours of initial notification
  • Take prompt action to correct the environmental deficiency, and, if unable to correct the deficiency in its entirety immediately, develop a corrective action plan to be submitted to and approved by DLA DES-E within 30 days of the initial notification.
  • Promptly notify, and provide applicable documentation to, environmental authorities and DLA DES-E within 24 hours of all reportable incidents, such as an accidental release of reportable quantities. Notification to regulatory authorities will comply with applicable laws and will even occur when it appears that the release was a result of a contractor’s actions to provide goods, services, or both on behalf of DLA.

 

2.3

Corrective Action

 

 

2.3.1

Root Cause

 

 

Depending on their severity or complexity, findings and/or nonconformances that do not have a quick resolution or are determined to be systematic should be evaluated for the underlying root cause (Root Cause Analysis Procedure). The majority of findings will not need a root cause analysis; the EMR/CAC will make this determination.

 

 

 

 

2.3.2

Corrective and Preventive Actions

 

 

The EMR may communicate lessons learned with the Depots so that the Depots will be aware of and learn from certain severe, repeat, or unique findings. Communications may come in the form of e-mails, conference calls, or other training materials. Information provided should include the finding and corrective and preventive action.

Corrective and preventive actions for safety and occupational health issues are evaluated via the risk assessment process prior to implementation.

 

 

 

 

2.3.3

Verification of Corrective and Preventive Actions

 

 

Each quarter, the current status or completion date of each outstanding corrective and preventive action, along with documentation of the implementation of the corrective and preventive action (photos, work orders, revised/updated work instructions, or SOPS, etc.) is reported to the EMR/CAC. The corrective and preventive action will be updated on the CASR by the EMR/CAC including the completion status and date.

The EMR/CAC will track and review metrics, including reductions in the severity of findings, time to closure, and number of repeat findings to evaluate the effectiveness of the our audit program and corrective and preventive actions. The metrics will be evaluated as part of the subsequent annual ESOHMS internal audit to ensure the measures have been effective in preventing recurrences. The subsequent audit will document the prior corrective actions taken, the results achieved, and the effectiveness of those actions.

The EMR/CAC is responsible for maintaining documentation of the findings and corrective and preventive actions, as well as communications with the regulators, in accordance with IGD 1016—Control of Records.

 

 

 

 

2.4

Reporting

 

 

Periodic ESOHMS status reports are prepared by the EMR and documented in the management review meeting minutes.

 

 

 

 

 

 

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