1.0 PURPOSE & SCOPE
The aim of this document is to provide guidelines for Company activities concerned with :
· how the company deals with a non-conformance, ie
· taking immediate action to mitigate any impacts caused
· running an investigation into the root causes
· the various corrective actions associated with non-conformances, or poorly functioning operational systems, whereby the aims include determining root causes of problems, removing or neutralising those causes
· the preventive actions, that is activities looking at ways of preventing problems happening in the first place
2.0 SCOPE
All activities, products, services and operational methods of Briarcare.
3.0 RESPONSIBILITIES
All employees have the responsibility of following this procedure and its associated documents.
All staff have a responsibility for reporting environmental incidents.
The Environmental Officer is usually involved with the investigation of the incident.
4.0 DEFINITIONS & ABBREVIATIONS
There is often a confusion over the meaning of the term “corrective action”, and some take it as meaning to “clean up the mess” left by an incident. In both ISO9001 and ISO14001, the term “corrective action” refers to the actions you should be taking, usually to the operational system, to stop the problem happening again. We will use the following expressions to distinguish specific actions :
Mitigation action action taken to sort out the immediate problem, eg clean up the mess, or stop the process, or isolate, contain and neutralise a spillage
Corrective action action taken to adjust the management system and/or process and/or activity and/or product design to prevent the recurrence of the problem.
Preventive action action taken to predict what problems might occur with a product and/or process or activity then adjust the product and/or process and/or activity and/or Company management systems, to prevent or reduce the chances (risks) of the problem occurring
For the EMS, we shall also make a somewhat technical distinction between a non-conformance and a non-compliance :
non-conformance an incident that does not conform to the requirements of
the EMS and the ISO14001 standard
non-compliance an incident (or non-conformance) that does not comply with legal requirements (sometimes called a legal non-compliance)
5.0 INCIDENTS & ACTING ON NON-CONFORMANCES
The aim is to ensure that whenever an environmental incident occurs, that it is acted upon, both to sort out the problem in the short term, and to prevent its recurrence in the longer term.
An environmental incident can arise from (or be reported by) several sources, for example :
· a weak, inadequate operating procedure, or even a lack of a suitable procedure
· a failure to follow the laid down operating procedures, usually through a misunderstanding
· unforeseen circumstances, such as abnormal operating conditions, or actions by an external agency
· emergencies (see also EN011)
· complaints (internally or externally to the organisation)
Mitigation action
The first actions should be immediate steps taken to reduce or eliminate any environmental impact from the incident. The immediate aim must be to gain control of the situation. Seek help from colleagues, and get advice from the Environmental Officer or a suitable deputy. The action taken should be appropriate to the magnitude of the problem.
Related documentation that may help :
EN011 Emergency Procedures – includes Fire
EN049 Spillage Control
EN056 Site Layout map
EN057 Emergency Equipment location
EN061 Drainage layout
EN062 Map of isolation valves & switches (eg useful for major leaks
from water supply system or switching off pumps)
Be prepared – read or study these before the incident.
Reporting Incidents
Initially, incidents should be reported verbally to the Environmental Officer or deputy, unless the situation is already known through involvement in controlling the situation and other mitigation action.
The Environmental Officer will decide if the incident is sufficiently serious to warrant recording it on a formal incident report form, EN032. If that is the case, proceed as below.
Investigation
Having taken the mitigation action, so that the situation is under control, record the details of the incident on the report form EN032, and the mitigation action taken.
Next, unless the situation is clear and does not require it, an investigation is required as to the root cause of the incident, with the aim of corrective action to prevent a recurrence. This cause may not be readily apparent in some cases, and require effort put into discovering it. There may be a small number where the root cause cannot be discovered.
If known, the investigator should indicate on the report form EN032 if the incident is believed to also be an instance of legal non-compliance, and enter the appropriate regulation etc onto the form.
Corrective Action
Having arrived at a root cause, corrective action is formulated, and a person made responsible to ensure it gets carried out. The actions should have deadlines associated with them. The person(s) carrying out the actions should sign the incident form to acknowledge they know about the requirements and deadlines.
Follow-up
Three main things to consider here :
· the corrective actions taken must be checked out to ensure they have been effective, and that the problem has been sorted out, and the incident form is “signed off”
· the relevant entries in the register of significant effects (EN029) should be re-visited and re-evaluated (EN003) to ensure that the relevant entries are still relevant; if found to be in need of change, the evaluation should be altered, and consideration given to how this reflects through to the management programme (EN008). If the incident has potentially severe and/or urgent consequences, top management should make the changes to the programme without waiting for the formal management review meeting.
· the incident is liable for discussion at the Management Review of the EMS, EN012.
Complaints
Please note that investigation of an incident may be triggered by a complaint, so that there may be some parallel work going on with a complain record. Cross-reference the records as appropriate, avoiding unnecessary duplication of effort.
6.0 CORRECTIVE ACTION
Corrective Action activities include, but are not limited to the following activities :
Complaints
The various procedures for dealing with complaints are summarised in EN018, as part of the processes for external communication. The exact treatment of a complaint will depend on the type of complaint. Corrective action is a feature of the response to a complaint, but its form will depend on the nature of the complaint. For the more conventional complaint, investigations will attempt to determine the root cause of the problem with the aim of corrective action to prevent a recurrence.
The aim is to respond quickly and decisively to complaints. A well handled complaint can enhance the company's image as well as preventing its recurrence.
Corrective Action Requests
Formal corrective actions can be generated as a result of non-compliances found during internal and external audits (see EN013 for details). They are subject to investigation to determine the root cause of the problem and follow up to determine the effectiveness of the corrective action. The audit generates a corrective action record (recorded on form F10).
Corrective action on any of the operational activities may be initiated without waiting for a formal audit to report something wrong. These are requested by anyone in the organisation by use of the same corrective action request form F10. That form can also be used to record the investigation into a non-conformity such as that of a product and/or process.
Corrective action forms may also be used to monitor actions arising from the management review meeting itself, or as a formal way of ensuring corrective actions matters arising from external audits of Briarcare’s EMS are actioned and completed.
The corrective action form can also be used as a formal way of recording the progressing of matters arising from audit “observations”, even though it’s not strictly a requirement of the audit system (EN013) to progress them.
The structure of the form is such that it aims to encourage the following sequence of events :
· The first main section is used to state the problem found; the user is also encouraged to look at work in progress and any related materials, products, processes and activities (actual or planned) that may require attention
· The next section allows the user to record any mitigation or immediate action taken at the time
· A section whereby the user can record their investigations, should the cause not be immediately obvious; the aim here is to discover the “root cause” of the problem wherever possible, because elimination of the root cause gives the best chance of stopping a recurrence of the same problem
· A section suggesting the corrective action to be initiated; occasionally the investigations will also suggest some preventive action – this too should be recorded
· An assignment of responsibility for the corrective action, (and any preventive action identified) including estimated target dates for completion
· A section to record the eventual action taken (if different)
· A sign off section where the manager or originator (or a suitable deputy) can confirm the action has worked, and leave brief notes of what was altered (eg a revision of a document)
The forms are logged and reviewed from time to time by the Environmental Officer for progress. If further investigations suggest that a delay may occur to the originally estimated time scale, the target date may be extended (eg more work needed than anticipated, or an item takes longer to deliver than anticipated).
They are also are subject to review by the Management Review meeting, EN012, particularly those that are proving difficult to resolve.
7.0 PREVENTIVE ACTION
Preventive Action activities include, but are not limited to, the following activities :
Planning activities
An essential part of preventive action is to properly plan the company’s activities and strategy with respect to environmentally related manners. Thus the company has, for example :
· planning of the introduction of new products, services, processes and activities, as in EN019
· a systematic evaluation of activities, process products etc in EN003
· a management programme to introduce various improvements in the EMS, and hence environmental impacts (EN008)
· a set of objectives (EN004) planned to drive the management programme
Preventive Action Requests
As with corrective action situation, there is a formal preventive action request form, F11, for anyone within the organisation that realises there could be a potential problem worthy of investigation and action.
The structure of the form is such that it aims to encourage the following sequence of events :
· The first main section is used to state the problem found; the user is also encouraged to look at work in progress and any related materials, products, processes and activities (actual or planned) that may require attention
· A section whereby the user can record their investigations into potential causes of the anticipated problem, should they not be immediately obvious in the previous sections; as with corrective action, the aim here is to attempt to discover what might be the “root cause” of the problem wherever possible, to give the best chance of stopping the problem happening
· A section suggesting the preventive action to be initiated; the same investigations may also throw up actual problems requiring corrective action, so this is also recorded
· An assignment of responsibility for the preventive action (and corrective action if appropriate), including estimated target dates for completion
· A section to record the eventual action taken (if different)
· A sign off section where the manager or originator can confirm the action has worked, and leave brief notes of what was altered (eg a revision of a document)
The forms are logged and reviewed from time to time by the Operations Director for progress. If further investigations suggest that a delay may occur to the originally estimated time scale, the target date may be extended (eg more work needed than anticipated, or an item takes longer to deliver than anticipated).
They are also are subject to review by the Management Review meeting, particularly those that are proving difficult to resolve.
The form can be used to assign responsibilities for the investigation and any subsequent action, as well as recording investigation results and the action taken. There is provision for the manager or originator (or a suitable deputy) to “sign off” the request form if it is believed to have been successful.
Complaints Analysis
Data from Customer Feedback (EN018) are analysed and can be published in reports from the Operations Director and/or used at Management Review Meetings. Generally one is looking for trends, ie spotting bad trends and initiating preventive and corrective action. This can also include watching out for improvements in trends following previous corrective actions, as an indication the action was the correct one to take. Any safety-related, or legal non-compliant problems are highlighted as soon as possible without waiting for trends to appear.
Analysis of Audits
Any type of audit result - from the internal audits, or customer audits, or approval body audits - maybe used as a basis for analysis of system performance. Such analyses are usually discussed at Management Review Meetings- see EN012.
Here one is usually considering :
· trends in audit results
· gap analysis (ie any activities missing)
· feedback - ie how others perceive the company’s performance
· what could be done to improve situations and perceptions
Any required actions are implemented and followed up from the meeting.
Loss Prevention activities
Briarcare has taken various steps within its operations to prevent loss to the company. These have been interpreted into the operational environmental procedures (eg EN020 through to EN027), and contain features such as :
· the general operational arrangements
· sections on what is deemed to be “best practice” for staff and contractors to follow
· other local rules, including prohibited activities
· preventive maintenance activities (142 OP)
· arrangements for environmental emergencies (EN011)