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Course 790 - Environmental Management Systems (EMS)

Safety guides and audits to make your job as a safety professional easier

Checking and Corrective Action

improvement project
Step 4: Check and correct the program.

Now let's discuss the next step of the EMS process, checking and corrective action. Checking evaluates how you are doing and corrective action responds to any issues you identify. Questions to ask include:

  • Are we doing what we said we would do? If not, why?
  • Are we making progress toward our objectives and targets?
  • Do we need to make any adjustments?

If you properly set up the tracking mechanisms during the planning and implementation steps, checking only represents making sure everything is being done and evaluating results. This is where it all starts to tie together.

Checking and Corrective Action has four elements:

  1. Monitoring and Measurement
  2. Nonconformance, Corrective and Preventive Action
  3. Records
  4. EMS Audit

Monitoring and Measurement

Monitoring and Measuring
Washing State Dept. of Ecology.

The first element in this phase is monitoring and measurement. This means that you track specific parameters that help:

  • Document that you are implementing the EMS,
  • Determine if you are meeting our objectives and targets,
  • Achieve operational control,
  • Calibrate monitoring equipment, and
  • Ensure compliance.

At this point, be sure to focus on what you found was significant during the initial planning phase. Examples of items that you might measure include:

  • chemical additions and concentrations in processes
  • temperature changes and extremes
  • percent of widgets meeting quality specifications
  • amount of hazardous waste generated
  • amount of solvent used for parts cleaning
  • use of checklists to determine compliance with applicable regulations
improvement project
Post key data to show performance.

You may want to use databases to track production data. Employees can use a computer or complete daily or weekly logs that are then provided to administrative personnel for data entry. It's a good amount of work, but it supports the production quality program as well as the EMS.

How to Use the Data

You might ask who looks at all of this data and how is it used. Supervisors and managers use it for a variety of purposes, including determining if the company is in conformance with the EMS. The data is also useful to plan for purchasing raw materials, staffing, and similar items.

You could also post key data on a bulletin board to show how well the company is doing; sharing information with staff helps keep the EMS moving in a positive direction.

The image to the right shows an example of an EMS tracking chart for production lines. The chart shows water use normalized per square foot of parts plated.

Non-conformance, Correcting, and Preventive Actions

correcting

No EMS is perfect. You will probably identify problems with your system (especially in the early phases) through audits, measurement, or other activities. In addition, your EMS will need to change as your facility adapts and grows.

Examples of non-conformance include:

  • Work instructions are not followed or records that document compliance with work instructions are not available (for example, required inspection logs are not completed)
  • Employees do not receive required training
  • Contrary to established procedures, contractors are allowed on-site to conduct work without meeting pre-approval criteria
  • The EMS documentation is not kept up-to-date

To deal with system deficiencies, your facility needs a process to ensure:

  • Problems (including nonconformities) are identified and investigated;
  • Root causes are identified;
  • Corrective and preventive actions are identified and implemented; and
  • Actions are tracked and their effectiveness is verified.

Identifying Trends

trends

EMS nonconformities and other system deficiencies, including legal noncompliance, should be analyzed to detect patterns or trends. Identifying trends allows you to anticipate and prevent future problems.

Key steps to identifying trends include:

  • Identify the problem;
  • Investigate to identify the root cause;
  • Come up with the solution;
  • Implement the solution;
  • Document the solution;
  • Communicate the solution; and
  • Evaluate the effectiveness of the solution.

Focus on correcting and preventing problems. Preventing problems is generally cheaper than fixing them after they occur. Start thinking about problems as opportunities to improve!

Determining the Causes

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The process of cause analysis occurs at two levels: surface cause and root cause. It's important to include both levels of analysis.

  • Surface Causes. These are those unique hazardous conditions and unsafe, inadequate, or inappropriate behaviors that occur during a process or procedure that have caused or contributed in some way to a nonconformity.
  • Root Causes. The root causes are the related underlying EMS weaknesses that somehow contribute to the conditions and behaviors we have identified. Whereas surface causes are unique, root causes can common effects throughout the entire EMS. EMS root causes can be categorized as follows:
    • EMS Design Root Causes: Inadequate design of one or more components of the EMS. The design of policies, plans, programs, processes, procedures and practices.
    • EMS Implementation Root Causes: Inadequate implementation of one or more components of the EMS. After each EMS component is designed, it must be effectively implemented. You may design an effective safety plan, yet suffer failure because it was not carried out properly. On the flip side, even if you effectively put into effect a poorly written safety plan, you will get the same results: failure. To achieve success, both EMS component design and implementation must be effective.

EMS root causes typically include:

  • poor communications
  • faulty or missing procedures
  • inadequate preventive or corrective maintenance program
  • lack of instruction and training
  • inadequate accountability program
  • lack of funding in support of corrective actions

You will need to establish a method to analyze the surface causes to determine the root causes of nonconformities in the EMS. If you're going to make any assumptions, assume the system has failed before making judgments about employee failures.

Root Cause Analysis Tools

root cause
Click to Enlarge

Root cause analysis is so important, we want to discuss it further. As we mentioned earlier, root cause analysis is a process by which you first analyze the surface causes of noncomformities to identify and analyze the underlying EMS root causes. For instance, if repeated spills commonly occur in your raw material transfer area, it's a clue root causes exist for the repeated nonconformity. To arrive at the root causes for the nonconformity, two tools can be quite helpful:

Root Cause (Fishbone) Diagram

The root cause diagram (also called a fishbone diagram) shown to the right is a good tool to help you organize your thoughts when conducting the analysis.

  • Each diagonal line represents a main component of the production process.
  • Each horizontal line stemming from the diagonal represents an important element contributing to each of the main components.

Five-Why Analysis

Another tool to help you identify root causes is called the 5-Why Analysis. This is a simple process of identifying the surface cause (write it as a problem statement) and then asking "why" five times to arrive at the root cause. To get the idea how this works, just think about a child who keeps asking why when you try to explain something.

Corrective and Preventive Actions

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Corrective actions involve doing something to eliminate or reduce a unique nonconformity (hazard or behavior) immediately. Corrective maintenance is a typical action to take. Notice that corrective actions focus on fixing the surface causes of a nonconformity: They do not address the root causes.

Preventive actions involve the improvement of EMS root causes such as the policies, programs, plans, processes, procedures, and practices that have common effects on the EMS. Writing and implementing a preventive maintenance plan is an example of a preventive action. Preventive actions focus on fixing the root causes: not the surface causes.

Once you discover the root causes for a nonconformity, you must correct them in a timely manner. It's also important to communicate findings to employees and provide follow-up training for changes in the procedures that may result.

The steps in this corrective and preventive action process to help complete corrective actions include:

  • Identify the problem - write the problem statement
  • Identify the causes - both surface and root causes
  • Devise actions- describe corrective and preventive actions
  • Implement actions - carry out corrective and preventive actions
  • Analyze actions - measure results and document
  • Communicate actions - complete instruction and training
  • Document actions - write an after-action report

Do the following to speed up the corrective and preventive action process:

  • Use a portion of your management review meetings to review nonconformities, discuss causes and trends, identify corrective actions, and assign responsibilities.
  • Be sure that your corrective and preventive action process specifies responsibilities and schedules for completion.
  • Review your progress regularly and follow up to ensure that actions taken are effective.
  • Find ways to get employees involved in the system improvement process.

Records

response

The checking and corrective action phase also includes records. As we discussed earlier, records are one level of EMS documentation. Records are objective evidence that prove EMS activities have been performed or that desired results have been achieved.

Records are objective and provide evidence of the results of following a procedure. For example, let’s say you have an Operational Control Procedure for a wastewater treatment plant. It states what you will do when you treat wastewater and how you will do it. The wastewater treatment system log sheets and database document that the procedure is followed and track your results; this comprises the record for that procedure.

Basically, records document that you are doing what you said you would do within your EMS, including:

  • training,
  • setting of objectives and targets,
  • identifying legal and other requirements,
  • implementing operational controls, and
  • following EMS system-level procedures.

When you audit the EMS, records are one type of documentation that will be reviewed.

Records provide a means of tracking the history of our EMS progress. Because they are part of the EMS and will be audited, EMS records must be kept in good order and should be readily retrievable. That is one reason that records are addressed in the EMS Document Control Procedure we discussed earlier. This brings us to the last item in the Checking and Corrective Action phase, EMS Audits.

Here’s a list of sample records that might be appropriate for your facility:

  • EMS audit
  • EMS Team and Advisory Committee meeting minutes
  • management review - presentation material and meeting minutes
  • copies of postings, memorandums or management bulletins that cover EMS topics
  • records of requests from public regarding the EMS policy or any external communication regarding significant environmental aspects
  • EMS employee awareness training records
  • registry of legal and other requirements

EMS Compliance and Conformance Audits

EMS audits check that the EMS system is implemented as planned. EMS audits are conducted internally or by outside parties to make sure the system is working or to support criteria related to certifications or participation in voluntary programs.

Compliance audits: An organization should periodically evaluate its compliance with the EPA, legal and other requirements applicable to its environmental aspects to ensure the commitment to compliance stated in its environmental policy statement. We encourage you to use this EMS Compliance Assessments Procedure (PDF) as a model for your own audit procedure.

Conformance audits: It should also conduct periodic conformance audits of its EMS to ensure that the system is structured and functioning in accordance with the ISO 14001 standard. You can open and use this EMS Conformance Audit Procedure (PDF) as a model for your own audit procedure.

Facilities which choose to implement an EMS that conforms to the ISO 14001 Standard can receive a formal registration. EMS auditors working for an organization that is accredited by ISO's Registrar Accreditation Board (RAB) will audit the facility's EMS to document that the EMS is implemented in conformance with the requirements of the standard. Once a facility passes the audit, they can claim that they are an ISO 14001 registered organization. The registration may help you compete with other companies in your industry. For example, most of the large automakers require that their suppliers are ISO 14001 registered.

If you have the time (1:20:51) take a look the two webinars below on EMS Auditing to Improve your EMS and Achieve Organizational Goals by the Washington State Department of Ecology.

Click to play video
Click to play video

Instructions

Before beginning this quiz, we highly recommend you review the module material. This quiz is designed to allow you to self-check your comprehension of the module content, but only focuses on key concepts and ideas.

Read each question carefully. Select the best answer, even if more than one answer seems possible. When done, click on the "Get Quiz Answers" button. If you do not answer all the questions, you will receive an error message.

Good luck!

1. In the Checking and Corrective Action process, you track specific EMS parameters that help _____.

2. Which of the following is important to deal with EMS system deficiencies?

3. What would you do if a spill occurs several times in your raw material transfer area?

4. Which of the following documents that you are doing what you said you would do within your EMS and provide a history of progress?

5. To make sure the EMS is working or to support criteria related to certifications or participation in voluntary programs _____ are conducted.


Have a great day!

Important! You will receive an "error" message unless all questions are answered.