ehs best practices for corrective and preventive actions

EHS BEST PRACTICE BP/1.8

EHS BEST PRACTICES FOR CORRECTIVE AND PREVENTIVE ACTIONS

JUNE 2016

EHS Best Practices for Corrective and Preventive Actions

Contents

1. Introduction .................................................................................9

2. Oil Industry ............................... Error! Bookmark not defined.

3. Objectives ...................................................................................10

4. Scope ............................................................................................10

5. Corrective and Preventive Actions ........................................11

Non-Conformance ................................................................................... 11Corrective Action ..................................................................................... 12Preventive Action .................................................................................... 13Disciplinary Process ............................................................................... 15Strategy ...................................................................................................... 15

6. Responsibilities ........................................................................16

Employees ................................................................................................. 16HSE Function ........................................................................................... 16Assigned Person for Analysis ............................................................... 16Assigned Person for Implementation ................................................. 16CPAR Originator ..................................................................................... 17

7. Corrective and Preventive Action Process ...........................17

8. Corrective and Preventive Actions for HSE MS ................19

9. Records ........................................................................................23

HSE Improvement Note ......................................................................... 24

10. Reference ....................................................................................25


Acronyms Acronym Description

BP Best Practice

CAPA Corrective Action and Preventive Action

ERC Energy Regulatory Commission

HSE Health, Safety and Environment

HSE MS Health, Safety and Environment Management System

ISO International Organization of Standards

MS Management System

QA Quality Assurance

SOP Standard Operating Procedures


Terminology Acronym Description

Audit An audit is an evidence gathering process. Audit evidence is used to evaluate how well audit criteria are being met. Audits must be objective, impartial, and independent, and the audit process must be both systematic and documented.

Audit Findings Audit findings result from a process that evaluates audit evidence and compares it against audit criteria. Audit findings can show that audit criteria are being met (conformity) or that they are not being met (nonconformity).

They can also identify improvement opportunities. Audit findings are used to assess the effectiveness of the quality management system and to identify opportunities for improvement.

CAPA CORRECTIVE/PREVENTIVE ACTION REQUEST.

Request to initiate a Corrective of Preventive Action

Conformity To conform means to meet or comply with HSE MS Requirements.

Continual Improvement Continual improvement is a set of activities that an organization carries out in order to enhance its ability to meet HSE Requirements. Continual improvements can be achieved by carrying out audits, self-assessments, management reviews, and benchmarking projects.

Continual improvements can also be realized by collecting data, analyzing information, setting objectives, and implementing corrective and preventive actions.

Defect Non-fulfillment of a requirement related to an Intended or specified use

Effectiveness Effectiveness refers to the degree to which a planned effect is achieved. Planned activities are effective if these activities are realized. Similarly, planned results are effective if these results are actually achieved.

HSE Audit An HSE Audit is a systematic and documented verification process of objectively obtaining and evaluating evidence to determine whether the Company is conforming to planned HSE arrangements


Acronym Description

HSE Performance HSE Performance will be measured using indicator that quantify and evaluate the organizational success in HSE. They measure how much success you’ve had and how much progress you’ve made relative to the objectives you wish to achieve. Indicators are also used to set measurable objectives, evaluate progress, monitor trends, make improvements, and support decision making. Indicators should be quantifiable and appropriate and should collect information that is useful to your organization and relevant to the needs and expectations of interested parties.

Internal Audit An audit is an evidence gathering process.

Audit evidence is used to evaluate how well audit criteria are being met. Audits must be objective, impartial, and independent, and the audit process must be both systematic and documented.

Machinery and Equipment

For the purposes of this best practice, machinery/equipment is defined as a system or device for doing work together with a power source and any associated auxiliary equipment.

Management System A management system is a set of interrelated or interacting elements that organizations use to implement policy and achieve objectives.

Non-conformance A non conformance is an activity or item that does not conform to the policies, procedures or other requirements of the HSE Management System.

Preventive Action Preventive actions are steps that are taken to remove THE CAUSES of potential nonconformities or potential SITUATIONS THAT are undesirable.

The preventive action process is designed to prevent the occurrence of nonconformities or situations that do not yet. It tries to prevent occurrence by eliminating causes.

While corrective actions prevent recurrence, preventive actions prevent occurrence. Both types of actions are intended to prevent nonconformities.

Preventive actions address potential problems, ones that haven't yet occurred. In general, the preventive action process can be thought of as a risk analysis process.

Preventive action is divided into 2 sets of actions – Risk


Acronym Description

Assessment and Continuous Improvement.

Preventive Action is different from Corrective Action in that Corrective Action is taken to prevent recurrence whereby Preventive Action is taken to prevent occurrence

Procedure A procedure is a way of carrying out a process or activity. According to ISO 9000, procedures may or may not be documented. However, in most cases, ISO 9001 expects you to document your procedures.

Documented procedures can be very general or very detailed, or anywhere in between.

While a general procedure could take the form of a simple flow diagram, a detailed procedure could be a one page form or it could be several pages of text.

A detailed procedure defines and controls the work that should be done, and explains how it should be done, who should do it, and under what circumstances. In addition, it explains what authority and what responsibility has been allocated, which inputs should be used, and what outputs should be generated.

Process A process is a set of activities that are interrelated or that interact with one another.

Processes use resources to transform inputs into outputs. Processes are interconnected because the output from one process becomes the input for another process.

In effect, processes are “glued” together by means of such input output relationships.

Organizational processes should be planned and carried out under controlled conditions.

An effective process is one that realizes planned activities and achieves planned results.

Quality The quality of something can be determined by comparing a set of inherent characteristics with a set of requirements.

If those inherent characteristics meet all requirements, high or excellent quality is achieved. If those characteristics do not meet all requirements, a low or poor level of quality


Acronym Description

is achieved.

Quality Assurance Quality assurance is a set of activities intended to establish confidence that HSE requirements will be met. Quality Assurance is one part of HSE Management.

Record A record is a type of document. Records provide evidence that activities have been performed or results have been achieved. They always document the past. Records can, for example, be used to show that traceability requirements are being met, that verification is being performed, and that preventive and corrective actions are being carried out.

Requirement A requirement is a need, expectation, or obligation. It can be stated or implied by an organization or other interested parties. A specified requirement is one that has been stated (in a document for example), whereas an implied requirement is a need, expectation, or obligation that is common practice or customary.

Review A review is an activity. Its purpose is to figure out how well the thing being reviewed is capable of achieving established objectives. Reviews ask the following question: is the subject of the review a suitable, adequate, effective, and efficient way of achieving the organization’s objectives?

There are many kinds of reviews. Some of these include management reviews, design and development reviews, and nonconformity reviews.

Root Cause Fundamental deficiency that results in a non-conformance and must be corrected to prevent recurrence of the same or similar non-conformance

Strategy A strategy is a logically structured plan or method for achieving long term goals.

According to ISO 9004, you need to develop a strategy and policies to ensure that the organization’s mission, vision, and values are accepted and supported by interested parties.

Verification Verification is a process. It uses objective evidence to confirm that specified HSE requirements have been met. Whenever specified HSE requirements have been met, a verified status is achieved.


Acronym Description

Work Environment The term work environment refers to working conditions. It refers to all of the conditions and factors that influence work.

In general, these include physical, social, psychological, and environmental conditions and factors. Work environment includes lighting, temperature, and noise factors, as well as the whole range of ergonomic influences. It also includes things like supervisory practices as well as reward and recognition programs.

Work Place Inspections Workplace inspections are planned, systematic appraisals of physical aspects of the workplace that identify HSE hazards and non-compliances with Company policies, procedures and practices and legal requirements.


1. Introduction

1.1. These Health, Safety and Environment Best Practices (HSE BPs), herein referred as “Best Practices (BPs)”, are guidance to Health, Safety and Environment (HSE) Practices for identifying, and investigating non-conformances and developing and tracking actions to closure and emergency situations and are produced by the Energy Regulatory Commission (ERC) in consultation with the National Transport and Safety Authority (NTSA), National Environment Management Authority (NEMA), Directorate of Occupational Safety and Health Services (DOSHS) and the Oil Industry in Kenya.

2. Disclaimer

2.1. The information contained in the BPs is not intended to be prescriptive, or to preclude the use of new developments, innovative solutions or alternative designs, materials, methods and procedures, so long as such alternatives provide an acceptable level of risk management.

2.2. The guidelines are provided for information and while every reasonable care has been taken to ensure the accuracy of its contents, the ERC cannot accept any responsibility for any action taken, or not taken, on the basis of this information.

3. OIL INDUSTRY

2.3. One of the growing concerns of the Oil Industry is proper management of petroleum operations. The growing complexity in the area is cause of concern for many companies.

2.4. Companies constantly strive for better and effective procedures. This is widely accepted that only trained professionals can cater to the expanding needs of the oil industry.

2.5. Recognized principles of HSE MS should include a component for process improvement, comprised largely of corrective and preventive action taken in response to identified problems.

2.6. The importance of identifying and investigating problems has been established in petroleum operations. Such problems can be identified in the following ways: error, incident, and accident reports; adverse reaction reports; process indicator measurements and results of internal or external audits, inspections, or assessments.


2.7. Responses to reported events can be remedial, in which the symptom is addressed, or corrective, in which the underlying cause is addressed with the intent to prevent recurrence.

2.8. If identified problems or their root causes are trended to look for patterns or problems not yet occurring are anticipated, the action taken is proactive and considered preventive.

4. Objectives

3.1. Preventive and corrective action is identified from inspection and testing, audits, hazard and incident reporting and other reviews of the HSE MS.

3.2. Corrective and preventive action is implemented to:

a. Detect and correct errors or problems in HSE Management

b. Prevent recurrences of errors or problems in HSE Management

c. Ensure that systems are in place to prevent the occurrence of errors or problems in HSE Management.

3.3. The purpose of the BPs is to:

a. Provide guidance on the establishment, implementation and maintenance of SOPs for dealing with actual and potential non-conformities and defining responsibility for handling corrective and preventive action.

b. Maintain records to demonstrate that non-conformances are handled in accordance with ISO 18000.

5. Scope

4.1. The corrective and the preventive action is one of the major areas for the oil industry. The entire concept of CAPA is constructed taking into considering the various industry needs.

4.2. The BPs apply to the Organization’s HSE MS and its controlled entities. It is imperative for the oil companies to train employees so that they can handle different aspects related to petroleum operations and regulation.

4.3. Some of the vital areas that should be touched upon by training programs are as follows:

a. Issue Review- Employees are trained to make a blue print of the entire situation at hand. This helps them making a better and comprehensive planning for meeting the challenges of the situation. The clear concept of issue review helps them in better analysis of the situation.


b. Root Cause Analysis- The root cause analysis training is one of the basic steps for the reaching up to the solution. Employees are trained to identify the root cause for the impending crisis. The solution is design in accordance to the nature and scope of the challenge. It is almost impossible to design any permanent solution without identification of the root cause.

c. Implementation and Effectiveness Checking- It is very important for employees to learn the methodology of implementing and monitoring the effectiveness of the entire procedure. This makes designing of corrective measures easier as the faults are indentified easily. Based on the results employees can be design changes in the system.

4.4. With proper introduction to all these processes and proper implementation of BPs at various levels, employees can cater to different challenges of the oil industry.

6. Corrective and Preventive Actions

Non-Conformance

5.1. A non-conformance is any deviation from the organization’s HSE MS. This includes deviation from the Company policy or standards, established HSE procedures, rules, regulations and voluntary commitments.

5.2. A non-conformance is often an indication of weakness or a flaw in the HSE Management System that requires corrective and/or preventive actions to improve the effectiveness of the management system.

5.3. Once a non-conformance is identified it is critical that systems are available and activated that ensure the most effective and feasible corrective actions are selected, responsibility is assigned, reasonable timeframe are defined and completion of the corrective actions are confirmed. These BPs will assist Companies to establish these important systems.

5.4. The organization shall establish and implement documented procedures for identifying and investigating non-conformance, developing effective corrective and preventive actions and tracking actions to closure. As a minimum, the procedure shall include the following elements:

a. A method to address and investigate potential or actual non-conformance which complies with HSE Standards

b. A method to assign responsibility and provide resources to initiate and complete corrective or preventive actions

c. A process to prioritize corrective or preventive actions based on the significance of risk


d. Setting deadlines for completion

e. A process to track corrective actions to closure and communicate status to Management and affected personnel

f. A quality assurance process to confirm that corrective or preventive actions are adequate and appropriate to address the non-conformance

5.5. This process must confirm that corrective actions effectively address the root cause(s), are appropriate for the significance of the non-conformance, are timed appropriately based on the seriousness of the non-conformance and are assigned to individual(s) with adequate authority and resources to complete the corrective actions

5.6. A method to follow-up on completed corrective actions to confirm that the intended results were achieved

Corrective Action

5.7. Corrective action is divided into two sets of actions. The first which is termed remedial action deals with the immediate problem.

5.8. The second action is defined in ISO 17025 as causal analysis. This action requires the question “Why did it go wrong?” to be asked instead of just “What has gone wrong?” Often the non-conformance is the symptom of an underlying problem.

5.9. By looking deeper into the operation and/or process, the root cause of the problem may be identified and by implementing the corrective action, the recurrence of a similar non-conformance would be reduced.

5.10. It may already be common practice to analyze the cause of any non-conformance that occur, but to comply with ISO 17025, a more systematic approach is needed.

5.11. Although cause analysis can be achieved partly by staff training, i.e. raising awareness among staff, it is more effective to incorporate the procedure into the quality system by introducing a section relating to cause analysis to any non-conformance notes.

5.12. The area where the non-conformance occurred should be revisited at a later stage to determine the efficiency of the corrective action possibly by an appropriate internal HSE audit.

5.13. There will not always be a deep seated problem within the HSE MS that has resulted in the recurrence of the non-conformance. The remedial action may be sufficient to eliminate the problem. In this case it is satisfactory to write “Not applicable” in the root cause section of the non-conformance note.


5.14. In practice, implementing the corrective action within the HSE MS does not require the documentation of a new procedure. It merely requires that existing procedures for dealing with non-conformances (anomalies) and internal audit include cause analysis as part of the process.

Preventive Action

5.15. There are two aspects to preventive action. The first is risk assessment and the second is continuous improvement.

5.16. There is a risk that any activity performed can breakdown. There are many procedures in place to prevent these failures from occurring including staff training, servicing equipment, monitoring equipment, validating methods and the use of quality control.

5.17. Consequently there is a high degree of confidence that these procedures are effective and correct results are obtained. A risk assessment must be performed when any new procedure is introduced or when any change to an existing procedure takes place.

5.18. In most situations, any new procedure undertaken involves adaptation of existing procedures of which the organization has considerable experience. Therefore it is sufficient to document the new procedure, ensuring that due consideration has been given to all the important critical control points and any risks associated with all activities within the process. SOPs should also address these factors.


5.19. Occasionally a new procedure is undertaken which is complex and of which there is little experience. In this situation it is advisable to perform a more formal risk assessment of the procedure. Typically this may involve producing a flow chart of the procedure, incorporating all key steps, documenting all the possible risks associated with each step, documenting how these risks should be minimized and lastly, documenting the procedure, taking into account all the critical control points.

5.20. The new process should be re-assessed after it has been used a few times and any amendments made as indicated. The whole process will generate records that should be filed as evidence that risk assessment (or preventive action) has taken place. It is important to judge when it is appropriate to adopt this rigorous approach to risk assessing a process.

5.21. The effectiveness of the procedure should be ascertained by ongoing internal quality audit and internal and external quality assessments.

5.22. Continuous improvement is a procedure that identifies and addresses improvements in the HSE MS and also potential sources of non-conformances.

5.23. A HSE Improvement Note can be used to assist in this process. Staff should be encouraged to identify possible improvements to the HSE MS or SOPs. Suggestions can be made at any time, but are most likely to be made during internal HSE audits. They can then be included in the Audit Report and a HSE Improvement Note raised in the same as Non-conformance Notes. Suggestions may be made following analysis of other areas of quality assurance and operations.

5.24. Improvement suggestions should be made on a HSE Improvement Note and considered by relevant staff. If it is decided that the suggestion is inappropriate, then this should be stated on the note and reason documented. If it is decided to act on a suggestion, all details should be documented including what has changed, what the change has achieved, details of SOPs that have been modified and any effects the change may have on other areas. If any validation needs to be carried out as a result of a change, then this should be cross referenced on the Quality Improvement Note.

5.25. At a management level, suggestions should be made at Management Review Meetings when Senior Management take a deeper look at the effectiveness of the HSE MS by reviewing HSE Performance. Suggestions can be noted as actions in the meeting minutes, but it is recommended that the HSE Improvement Note is also used to initiate and track actions.

5.26. HSE improvement suggestions should be reviewed at future Management Review Meetings.

5.27. Note 1 in Section 4.12 on preventive action in ISO 17025 describes preventive action as “a pro-active process to identify opportunities for improvement rather than a reaction to the identification of problems or


complaints”. Continuous improvement is essential for the ling-term success of any organization. Use of HSE Improvement Notes will facilitate this process.

Disciplinary Process

5.28. The organization shall establish a program to implement appropriate disciplinary action in the event of knowing violations to HSE policies, rules, regulations, procedures or training.

5.29. Discipline should be designed with the intent to address root causes. The program must include the following elements:

a. Employee disciplinary action for knowing violations

b. Supervisor disciplinary action when supervisors are aware of and allow violations within their area of responsibility

c. Supervisor disciplinary action when supervisors, through the proper performance of their duties, should have been aware of violations

5.30. Where a general disciplinary program is already established, these HSE requirements shall be incorporated in the existing program

5.31. The information contained in the BPs is not intended to be prescriptive, or to preclude the use of new developments, innovative solutions or alternative designs, materials, methods and procedures, so long as such alternatives provide an acceptable level of risk management.

5.32. The guidelines are provided for information and while every reasonable care has been taken to ensure the accuracy of its contents, the ERC cannot accept any responsibility for any action taken, or not taken, on the basis of this information.

Strategy

5.33. To comply with ISO 17025 and ISO 15189 it will be necessary to formalize SOPs for both Corrective and Preventive Actions.

5.34. It is relatively easy to produce forms to record and track these processes and also to document the required SOPs.

5.35. This change is best achieved by regularly discussing all aspects of HSE Performance at staff meetings and encouraging discussions about observed and potential problems.


7. Responsibilities

Employees

6.1. It is the responsibility of all employees to report non-conformances using the CPAR

HSE Function

6.2. It is the responsibility of the HSE Function to oversee full implementation and maintenance of this best practice.

6.3. The HSE Function is responsible for:

a. Assigning the CPAR for analysis to staff

b. Review the Action Plan proposed by the Assigned Person for analysis

c. Assign responsibility for implementation of Action Plans

d. Review implemented Action Plans

e. Review the effectiveness of Action Plans

f. Assign number to CPAR and maintain CPAR Register

g. Review CPAR for accuracy and completeness

h. Monitor CPAR status and update register

i. Provide copy of completed CPAR to Originator

j. File copies of objective evidence which support verification and validation of closure of CPAR

Assigned Person for Analysis

6.4. The Assigned Person for Analysis is responsible for:

a. Review the CPAR and determine necessary Corrective/Preventive Actions

b. Perform root cause analysis and determine Action Plans for justified CPAR

c. Propose to HSE Function the implementation of Action Plans

Assigned Person for Implementation

6.5. The Assigned Person for Implementation is responsible for:

a. Conduct detailed study and take appropriate action


b. Implement the approved Action Plan

c. Sign the CPAR and forward it to the HSE Function for review and approval

CPAR Originator

6.6. The CPAR originator is responsible for initiating the CPAR when corrective/prevention action is required and submitting to the HSE Function

8. Corrective and Preventive Action Process

7.1. The Company should develop and implement procedures that:

a. Identify and correct non-conformities and take actions to mitigate HSE consequences

b. Investigate non-conformities, determining their cause and taking action to prevent recurrence

c. Evaluate the need for actions to prevent non-conformities and implement appropriate actions to prevent recurrence

d. Record and communicate the results of preventive and corrective actions

e. Review the effectiveness of corrective and preventive actions

f. The CPAR shall be initiated whenever a condition warrants an investigation to determine if corrective or preventive action is required.

7.2. Corrective or preventive action shall be initiated as a result of but not limited to the following:

a. Non-conformances identified during internal or external audits

b. Action items from Management Review of the HSE MS

c. HSE related complaints

d. HSE problems identified by employees

e. Potential Incidents, Near Misses and Incidents

7.3. Review of trends or significant discrepancies discovered by analysis of non-conformance reports.

7.4. The HSE Function shall verify that required fields are appropriately and unambiguously filled, assign CPAR number, update CPAR Register and forward the CPAR to the Assigned Person for Analysis

7.5. The Assigned Person for Analysis reviews the CPAR and determines if any corrective or preventive action is necessary


7.6. Where necessary the Assigned Person for Analysis shall conduct a root cause analysis, determine the corrective/preventive actions and the person responsible for implementation.

7.7. The HSE Function will review the proposed corrective/preventive actions and assign responsibility for implementation

7.8. The HSE Function will follow up on the implementation of the corrective action and submit the completed CPAR to the originator.

7.9. The HSE Function shall analyze the patterns and trends in Corrective and Preventive Action Data in order to monitor the timeliness and adequacy of corrective and preventive actions and identify additional opportunities for improvements to the HSE MS.


9. Corrective and Preventive Actions for HSE MS

The corrective and preventive actions undertaken as part of the HSE MS are outlined in the table below.

Activity Procedure Corrective action Preventive action Requirements

Workplace inspections

Workplace inspection program

HSE monitoring and measurement

Addressing non-conformances with HSE procedures and systems identified during inspection (using reference checklist)

Implementing improvements to HSE systems and procedures

• Actions necessary are recorded on inspection worksheets;

• Tasks and date of completion are assigned to the most appropriate person to complete the task;

• Form is returned to the HSE Function when task complete, who monitors that the action is completed in a timely fashion.

HSE Audits HSE audits Addressing non-conformances with HSE procedures and systems identified during audits

Implementing improvements to HSE systems and procedures

• Audit report provided by HSE Function and closing meeting outlines actions to be taken including timelines;

• HSE Function monitors and assists with implementation;

• HSE Function monitors completion of actions at end of time period allocated.

Hazard & incident

Procedures for hazard & incident reporting,

Addressing problems and non-conformances with

Addressing problems and non-conformances with

• Hazard or incident reported on hazard & incident report form;



reporting investigation & recording

HSE procedures and systems that led to the incident

HSE procedures and systems that resulted in the hazard

• HSE Function and HSE Committee provide feedback and assistance with actions;

• HSE Function and HSE Committee monitor effectiveness of action;

• Outstanding corrective actions report monitors completion of corrective/preventive action.

Inspection & testing of machinery & equipment

Use, design and modification of machinery and equipment

Procedure for in-service inspection, testing & tagging of electrical equipment

Procedures for isolation of machinery/equipment

Addressing problems identified with plant and equipment and non-conformances with test specifications

Implementing improvements to plant and equipment and to systems and procedures that use the plant and equipment.

• Results of testing provided to unit;

• Non-conformances reported to HSE Function and Maintenance Manager;

• Plant and equipment placed out of service until repaired/undergone maintenance and retesting;

• Replaced by equipment with safer design.

HSE document review

HSE procedures for document control and retention

Addressing problems identified that require policy documentation, legislative requirements, issues arising with procedures and systems

Implementing improvements to policy documentation to prevent system and procedural non-conformances

• Procedure for policy/procedure development and implemented

• Policies, procedures, guidelines reviewed every 3 years.



Issues raised at HSE Committee Meetings

Procedures for HSE consultation

Procedures for HSE issue resolution

Procedures for hazard & incident reporting, investigation & recording

Addressing individual, system or procedural HSE problems and/or complaints

Implementing improvements to HSE systems or procedures

• Staff informed of meetings to raise issues;

• Issues discussed at zone HSE Committee Meetings with staff members invited to attend;

• Discussion and resolutions included in minutes;

• Items remain on agenda until actions completed;

• HSE Function ensures issues with Companywide implications are referred to HSE Committee for resolution and action, if required.

Review of HSE projects and plans

HSE Committee Meetings

Addressing problems identified at review, taking action to correct problems in ensuing projects and plans

Implementing improvements to HSE projects and plans

•

Management review

Quarterly and annual reviews held by HSE Committee

Addressing problems identified at review, taking action to correct problems in ensuing projects, plans, policy documents, systems and procedures

Implementing improvements to HSE projects, plans, policy documents, systems and procedures

• Discussion and actions required included in minutes;

• Actions followed up at subsequent meetings.



External and internal reviews

Addressing problems identified at review, taking action to correct problems in ensuing projects, plans, policy documents, systems and procedures

Implementing improvements to HSE projects, plans, policy documents, systems and procedures

• Discussion and actions required included in HSE Committee minutes;

• Actions incorporated into new projects, plans, policy documents, systems and procedures.

• Actions followed up at subsequent meetings.

EHS Performance Assessment of the Downstream Petroleum Sub-sector HSE Best Practices for Corrective and Preventive Actions

10. Records

9.1. The following corrective and preventive action records must be documented and maintained:

a. Results of all investigations into non-conformance including the date and location of the investigation, names of investigators, root and contributing causes and recommendations or corrective actions

b. Documentation of all corrective or preventive actions resulting from non-conformance investigations including descriptions of the actions, timelines or deadlines, names of those assigned to initiate and complete the actions, documentation of action closure and results of follow-up activities to confirm that the intended results were achieved

c. Results of the quality control process by HSE Standards

d. Records of disciplinary actions taken as a result of knowing violations to HSE policies, rules, regulations, procedures or training

e. CPAR

f. Hazard and Incident Report Forms

g. HSE Committee Minutes

h. Records of audits, including:

i. Self-Audits

ii. Internal Audits

iii. External Audits

iv. Certification Audits

i. Records of workplace inspections


HSE Improvement Note

HSE I NO.

Nature of HSE Improvement Suggestion, including area and/or unit concerned, where appropriate:

Person making HSE Improvement Suggestion Dated

Person responsible for considering HSE Improvement Suggestion

Action taken including details of any consequences and SOPs changed:

Signed: Date:

Action Close: Y/N Signed: HSE Manager Date:


11. Reference

10.1. Occupational Health and Safety Act 2007

10.2. IS0 18001

10.3. ISO 9000:2008

10.4. Model HSE MS

ehs best practices for corrective and preventive actions

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