***1.0 Purpose:*** To establish processes for initiating corrective and
preventive actions in the (AGENCY) Headquarters and its sites'
(henceforth site(s)) ESHMS so as to correct non-conformities, prevent
them from potentially occurring in other areas of the organization, and
to initiate improvements to the system. The purpose of the corrective
action process is to eliminate the recurrence of nonconformities. The
purpose of the preventive action process is to eliminate the potential
of nonconformity in other parts of the organization.

***2.0 Scope:*** This procedure applies to all site activities conducted
that are within the scope of the ESHMS. The procedure also applies to
any off-site ESH activities.

***3.0 Nonconformity, Corrective & Preventive Actions:*** Whenever a
nonconformity in the ESHMS is detected, the ESHMS Coordinator shall be
notified immediately. The ESHMS Coordinator shall confer with the
affected site operational manager, employees and/or employee
representatives, on the proper corrections to take in order to mitigate
any (potential) impacts caused by the nonconformity and for initiating
and completing a corrective action and any necessary preventive actions.

Incident investigations should begin as soon as practical and in many
cases right after an "event," "close call" or "near miss". The goal is
to identify and correct deficiencies before any human injury or
environmental impact occurs. The incident investigation process should
define what needs to be investigated, timeframes for an investigation,
who should participate, and how recommendations to prevent recurrence
should be generated and communicated.

> ***3.1 Corrective Actions:*** Corrective actions are completed by the
> operational manager in the affected area where the nonconformity
> occurred or as otherwise determined for the particular impact or
> incident. The operational manager will expedite action on inadequately
> controlled hazards/aspects, identify any newly created hazards/aspects
> resulting from corrective action, track actions to ensure effective
> implementation and communicate the completion of the corrective action
> in writing to the ESHMS Coordinator on the Corrective Action Request
> (CAR) form. The corrective action taken shall be sufficient to
> eliminate the root causes of the actual nonconformity. (See the
> Corrective Action Request form in the ESHMS Audit Program.)
>
> ***3.2 Preventive Actions:*** Once a corrective action has been
> implemented, the ESHMS Coordinator will confer with affected
> operational managers in other areas or functions of the site that have
> similar vulnerabilities to that which caused the original
> nonconformity. These managers are responsible for ensuring that the
> preventive action is completed in their areas or functions as agreed
> with the ESHMS Coordinator. They will expedite action on inadequately
> controlled hazards/aspects, identify any newly created hazards/aspects
> resulting from preventive actions, track actions to ensure effective
> implementation and, communicate the completion of the preventive
> action in writing to the ESHMS Coordinator through the completed CAR
> form.
>
> ***3.3 Obstacles and Barriers:*** The ESHMS Coordinator shall identify
> and remove any obstacles or barriers to employee participation and
> record changes to any of the documented ESHMS procedures that may be
> affected as a result of the corrective and preventive actions.
> Examples of obstacles or barriers include lack of response to employee
> input or suggestions, reprisals, or other forms of discrimination. A
> common mechanism for achieving employee participation is involvement
> in environmental awareness or health and safety committees.

# *4.0 Records:* The ESHMS Coordinator or other designated member of the CFT will maintain the following records generated by this procedure:

-   The list of ESHMS nonconformities in the last three years, the date
    of each occurrence, the date of corrective action, and date of
    completion of preventive action, if applicable (See CAR form).

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-   Documentation of the analysis of the root causes of nonconformities
    (See CAR form).

Hardcopy or electronic versions of these records will be maintained in a
central and accessible file (e.g., the ESHMS Manual).

> ***4.1 Employee Access to Records:*** Management will provide
> employees with access to CARs as appropriate to maintain employee
> confidentiality with respect to health and safety, or other employee
> medical and exposure data. This information may be provided through
> the ESHMS Manual or through other documentation maintained by the
> ESHMS Coordinator, or other designated member of the CFT.