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TitleCAPA-SOP
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Page 1

Nonconformance and
Corrective and
Preventive Action
Background and Exhibits
No EMS is perfect. You will probably identify prob-
lems with your system (especially in the early phas-
es) through audits, measurement, or other
activities. In addition, your EMS will need to
change as your facility adapts and grows. To deal
with system deficiencies, your facility needs a
process to ensure that:

• 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.

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 Causes of Problems

You will need to establish a method to determine
the causes of failing to conform. In some cases, the
cause may be obvious, and in others, obscure.

EMS problems typically include:

• Poor communication;
• Faulty or missing procedures;
• Equipment malfunction or lack of

maintenance;
• Lack of training;
• Lack of understanding of requirements;
• Failure to enforce rules; and
• Corrective actions fail to address root causes

of problems.

“Root cause analysis” is a process by which you
can identify causes and preventive actions. If a spill
occurs several times in your raw material transfer
area, you would attempt to identify the root cause
of the spill occurring so that you could address the
cause and prevent the spill in the future.

Root cause analysis can be used to describe a very
formal analysis process, however, it also can mean
something simpler, looking past the obvious or im-
mediate reason for a nonconformance to
determine why the nonconformance occurred.

The root cause diagram, shown in Exhibit 15-1:
Root Cause Diagram, will help you organize your
thoughts when you analyze your facility’s potential
for environmental impact. This analysis can be done
by one person or by a group, with one person writ-
ing down the ideas produced. Each diagonal line
represents a main component of the production
process. Each horizontal line stemming from the di-
agonal represents an important element contribut-
ing to each of the main components. For example,
elements of work practices might contribute to the
labor component. This diagram is a device to help
organize the analysis of the cause of potential envi-
ronmental impacts. Use it if it helps, but don’t get
hung up on trying to make it work.

Plan · Do · Check/Act

Module
Nonconformance and Corrective and Preventive Action 15-1

Page 2

Exhibit 15-1: Root Cause Diagram

Taking Corrective Action

Once you document a problem with respect to
meeting targets, you must resolve it. Take action as
quickly as possible. Make sure assigned responsibili-
ties for actions and schedules are clear so that cor-
rection occurs in a timely manner.

Employees in the facility may recognize the need for
corrective action and provide good ideas for solving
problems. Find ways to get them involved in the im-
provement process. It’s important to determine
whether a lapse is temporary or due to some flaw in
the procedures or controls. For this reason, commu-
nicate any findings to employees and provide any
follow-up training for changes in the procedures
that may result. The following is a checklist to help
complete corrective action. Have you:

• Identified the problem(s)?
• Identified the cause(s)?
• Come up with a solution for each?

• Implemented the solution(s)?
• Documented the solution(s)?
• Communicated the solution(s)?
• Documented the action(s)?

Here are some things to think about to expedite
the determination of your facility’s corrective and
preventive action process:

• Use the corrective and prevention action
process for quality that is included in your ISO
9001 management system, if you have one, as a
model (or integrate with it) for EMS purposes.

• Combine some elements of your management
review and corrective action processes if you
can. Facilities that do use a portion of their
management review meetings to review non-
conformities, discuss causes and trends, iden-
tify corrective actions, and assign
responsibilities.

• Don’t go overboard with bureaucracy—simple
methods often work quite effectively. The
amount of planning and documentation need-
ed for corrective and preventive actions will
vary with the severity of the problem and its
potential environmental impacts.

• Be sure that your corrective and preventive ac-
tion process specifies responsibilities and
schedules for completion. Once you
document a problem, the facility must be
committed to resolving it in a timely manner.
Review your progress regularly and follow up
to ensure that actions taken are effective.

• Make sure your actions are based on good in-
formation and analysis of causes. While many
corrective actions may be “common sense,”
you need to look beneath the surface to deter-
mine why problems occur.

• Rule of thumb: Corrective actions should: (1)
resolve the immediate problem; (2) consider
whether the same or similar problems exist
elsewhere in the organization; and (3) prevent
the problem from recurring. The corrective
action process also should define the respon-
sibilities and schedules associated with these
three steps.

• Find ways to get employees involved in the
system improvement process (for example, via
suggestion boxes, contests, or incentive pro-

EMS Implementation Guide for the Shipbuilding and Ship Repair Industry

Module
15-2 Nonconformance and Corrective and Preventive Action

Page 3

grams). Initially, most EMS problems may be
identified by your internal auditors. However,
over the long run, many problems and good
ideas may be identified by the people doing
the work. This should be encouraged.

Use your answers to the questions provided in
Exhibit 15-2: Element Review Questions to begin
the process of determining your facility’s corrective
and preventive action process. Exhibit 15-3:

Procedure for Corrective and Preventive Action
(EP-015), and supporting forms (EF-015.01, EF-
015.02), provide a sample procedure and forms for
conducting corrective and preventive action. The
supporting forms are guides to document the use
of your procedure and to track corrective and pre-
ventive actions.

Plan · Do · Check/Act

Module
Nonconformance and Corrective and Preventive Action 15-3

Questions Your Answers

Do we have an existing process for corrective and
preventive action?

If yes, does that process need to be revised?
In what way?

Who needs to be involved in this process within
our organization?

How are nonconformities and other potential system
deficiencies identified? (List methods such as audits,
employee suggestions, ongoing monitoring, etc.)

How do we determine the causes of nonconformities
and other system deficiencies?
How is this information used?

How do we track the status of our corrective and
preventive actions?

How is/can information on nonconformities and
corrective actions be used within the EMS
(for example, in management review meetings, in
employee training sessions, in review of procedures, etc.)

How do we ensure the effectiveness of our corrective
and preventive actions?

Our next step on corrective and preventive
action is to…

Exhibit 15-2: Element Review Questions

Page 4

EMS Implementation Guide for the Shipbuilding and Ship Repair Industry

Module
15-4 Nonconformance and Corrective and Preventive Action

1.0 Purpose
The purpose of this procedure is to establish and outline the process for identifying, documenting,
analyzing, and implementing preventive and corrective actions. Preventive or corrective actions may
be initiated using this procedure for any environmental problem affecting the organization.

2.0 Activities Affected
All areas and departments

3.0 Forms Used
3.1 Corrective and Preventive Action Request (CAR) (EF-015.01)

3.2 Corrective and Preventive Action Tracking Log (EF-015.02)

4.0 References
4.0 Procedure for Environmental Management System and Regulatory Compliance Audits (EP-017)

4.1 Procedure for Emergency Preparedness and Response (EP-007)

4.2 Procedure for Communication with Stakeholders (EP-004)

4.3 Procedure for Document Control (EP-014)

4.4 Procedure for Monitoring and Measurement (EP-009)

4.5 ISO 14001:1996, Element 4.5.2

5.0 Definitions
None

6.0 Exclusions
None

7.0 Procedure
7.1 Where non-conformances or non-compliances are identified through the environmental au-

dit process, the responsible and accountable area or department representative, affected
area or department manager, audit team member or Environmental Management
Representative (EMR), is responsible for:

7.1.1 Identifying the root cause(s) of non-conformances or non-compliances;

7.1.2 Identifying appropriate corrective and preventive actions (including modifying or
creating environmental procedures and work practices);

7.1.3 Planning and implementing corrective and preventive actions; and

7.1.4 Verifying the close-out and effectiveness of corrective and preventive actions.

Exhibit 15-3: Procedure for Corrective and Preventive Action (EP-015)

Page 5

Plan · Do · Check/Act

Module
Nonconformance and Corrective and Preventive Action 15-5

7.2 Where non-conformances are identified outside the environmental audit process, the
Quality Manager or designee will generate a CAR, as appropriate. The affected area or
department manager, or designee, is responsible for:

a) Identifying the root cause(s) of these non-conformances;

b) Identifying appropriate corrective and preventive actions (including modifying or creat-
ing environmental procedures and work practices);

c) Planning and implementing corrective and preventive actions; and

d) Verifying the close-out and effectiveness of corrective and preventive actions.

The Quality Manager or designee will verify proper implementation of corrective and
preventive actions.

7.3 Where non-compliances are identified outside the environmental audit process, the EMR or
designee will generate a CAR, as appropriate.

8.0 Frequency
As needed following reviews

9.0 Records
Records shall be retained consistent with the Procedure for Environmental Records (EP-005).

Record of Revisions
Revision Date Description Sections Affected

Exhibit 15-3: Procedure for Corrective and Preventive Action (EP-015) (continued)

Page 6

A. Audited Area/Department:


Audit Date:

Auditee(s):

Auditor(s):

Date:

C. Root Cause Analysis: B. Description of Non-Conformance:















Audit Criteria:

Applicable ISO 14001 Element:



D. Corrective Action:




















Date of Implementation:

E. Preventive Action:


















Date of Implementation:

F. Verification:



Date of Verification:
Auditor (signed):



Date:



Corrective and Preventive Action Request (EF-015.01)

EMS Implementation Guide for the Shipbuilding and Ship Repair Industry

Module
15-6 Nonconformance and Corrective and Preventive Action

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