Ensure that Members of the Workforce complete the training identified in ESH100.4.FI.3 prior to performing the indicated work activity or fulfilling the indicated role.

Note: See Sandia corporate procedure HR100.2.1, Identify and Complete Sandia Required Training for all Members of the Workforce.

Ensure that Members of the Workforce (see the Corrective Action Verification of Completion and Validation of Effectiveness Flowchart to view the complete process): 

Note: A list of Potential ES&H Issues can be viewed under the Tools section.

• Perform the causal analysis at the appropriate level of rigor. Refer to Causal Analysis Graded Approach under Tools section.
• Develop corrective actions through an organized team that includes a causal analyst trained at the appropriate level (see CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, for training requirements). Refer to “Development of Corrective Actions" in the Guidance for Corrective Action Management under Guidance section.
• Write the corrective actions. 

  Notes:

• • Writing corrective actions pertains to documenting the corrective actions.
  • Completing corrective actions is the process of completing the action stated in the documented corrective action.
• Complete the corrective actions identified in the written document.
• Bring the corrective actions into existence.
• Store the corrective action evidence appropriately.
• Provide the corrective action evidence to the appropriate program personnel or division ES&H coordinator as designated in Table 1.
• Approve the changes in the scope of a corrective action through SNL management and the appropriate oversight personnel.

Ensure that Members of the Workforce perform verification and validation of corrective actions for programs detailed in Table 1.

Note: Refer to “Effectiveness of Corrective Actions” and “Corrective Action Sustainability” in the Guidance for Corrective Action Management under the Guidance section.

• Derive corrective actions from the causal analyses. Refer to “Development of Corrective Actions” in the Guidance for Corrective Action Management under the Guidance section.
• Write corrective actions to correct causes and prevent reoccurrence of the incidents in the future, once the causes of the incidents have been determined. 

  Note: For those programs requiring validation of effectiveness, the last corrective action must state “validation of corrective action effectiveness will be performed.” Refer to “Effectiveness of Corrective Actions” and “Corrective Action Sustainability” in the Guidance for Corrective Action Management under the Guidance section.

• Follow the requirements at the 857 website, "857 Internal Audit: ES&H, S&S, and IT Operations."
• Focus on solutions, when developing proposed corrective actions, that:
  • Prevent recurrence.
  • Are feasible.
  • Meet organizational and corporate goals.
  • Are consistent with ES&H and other safety-related constraints.
  • Do not introduce new risks.

• Ensure that the corrective action evidence is adequate. Refer to “Maintaining Evidence Files” in the Guidance for Corrective Action Management under the Guidance section.
• Review programmatic requirements to ensure compliance.
• Ensure evidence is in physical form; examples include: (Refer to “Maintaining Evidence Files” in the Guidance for Corrective Action Management under the Guidance section.)
  • Causal analysis.
  • Corrective action plan.
  • Corrective action closure.
  • Correspondence.
  • E-mails.
  • Memos.
  • Revised documentation.
  • Photos.
  • Drawings.
• Store evidence:
  • Store evidence according to programmatic and corporate records management requirements.
  • Store evidence in a corporate management records center or EIMS.
  • Link evidence with an identifier back to the specific event.
  • Document where the evidence is stored. 

    Note: Follow individual programmatic processes for this step.

• • Designate a contact that can locate and provide the evidence.
  • Follow the requirements at the 857 website, "857 Internal Audit: ES&H, S&S, and IT Operations."

¹See CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews, for training requirements. Note: Meet the Nuclear Safety Rule (PAAA) requirement to send corrective action evidence to the SNL Safety and Security Regulatory Support Program (SSRSP) office.

Note: Refer to “Effectiveness of Corrective Actions” and “Corrective Action Sustainability” in the Guidance for Corrective Action Management under the Guidance section.

Administrative

Added

• CG100.6, Assure Performance Process (Related Corporate Processes & Procedures)
• DOE G 414.1-5, Corrective Action Program Guide (Forms, Links & Tools)

Modified

Moved DOE G 450.4-1B, Integrated Safety Management System Guide from "Additional Drivers" section and to the Guidance documents in "Forms, Links & Tools."

Administrative

Modified

• Changed Department 12870 to 857 and added link in Table 1.
• Modified the HTML to properly align notes in the Requirements & Instructions.

Added

• Added the following note in the Requirements & Instructions in the "Verify and Validate Corrective Action Effectiveness" activity:  "Note: Refer to “Effectiveness of Corrective Actions” and “Corrective Action Sustainability” in the Guidance for Corrective Action Management under the Guidance section."
• Added the following note to Table 1:  "Note: Refer to “Effectiveness of Corrective Actions” and “Corrective Action Sustainability” in the Guidance for Corrective Action Management under the Guidance section."

Administrative

Modified

• Corrected link to the SNL SSRSP website.  (Forms, Links & Tools)
• Corrected typo (Requirements & Instructions)

Administrative

Modified

• Changed subject matter expert from Karen Armstrong to Heidi Herrera.
• Changed "12857 website" references to "857 website."
• Note in footnote of Table 1 now states to send corrective action evidence to the SNL SSRSP office instead of the SNL PAAA office.  
• Updated websites and tools sections under Forms, Links & Tools.
• Replaced DOE5480.19, Chg 2 with DOE O 422.1. (Requirement Drivers)
• Revised Additional Drivers list.

Added

• References to the "Guidance for Corrective Action Management" document.  (Requirements & Instructions and Forms, Links & Tools)

Removed

Reference "ES&H Issues Management (corrective action)" program from Table 1.  The information is now contained within the Corrective Action Management Program.

Administrative

Modified

• Updated SAPLE link for subject matter expert for system consistency.
• Removed extra blank line in Applicability field.
• Corrected date format in change summary to include 2-digit months.

Administrative

Added

• Link to CATS application

Administrative

Modified

• Updated reference and link From: 12870 website, 12870 "Quality, Safeguards and Security Assessments" To: 12857 website, 12857 "Internal Audit: ES&H, S&S, and IT Operations."