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Policy Area

ESH-Environment Safety & Health

Procedure Number

ESH100.4.FI.3

Procedure Title

Implement and Manage Corrective Actions

Procedure Manager

BENDURE, ALBERT O.

Status

Active

Subject Matter Expert

  • Karen N. Armstrong

Applicability, Exceptions, and Consequences

This corporate procedure applies to all Members of the Workforce who develop, verify completion of, or validate effectiveness of corrective actions.

Exceptions to, or deviations from this procedure must be approved through the Executive Policy Sponsor or Policy Area Manager, if delegated. Click here to view Contacts for Corporate Policy System Policies, Processes, and Procedures. See CG100.1.7, Request an Exception to a Policy, Process, or Procedure, for directions on how to obtain an exception to this procedure.

Granting or permitting exceptions or violations of policy, process, or procedure without authority, regardless of position or title, may be cause for disciplinary action up to and including termination of employment. Violating a policy, process, or procedure may be cause for disciplinary action up to and including termination of employment.

IMPORTANT NOTICE: A printed copy of this document may not be the document currently in effect. The official version is located on the Sandia National Laboratories Sandia Restricted Network (SRN).

Procedure Overview

This procedure integrates the requirements for verification and validation of corrective actions resulting from events such as audits, self-assessments, occurrences, and Price-Anderson Amendments Act (PAAA) Nuclear Safety Rule nonconformances.

Procedure Requirements

Training

Activity Responsible Individual Required Action
Ensure Training Compliance Managers

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.

Procedure Requirements

Activity Responsible Individual Required Action
Provide Oversight of Corrective Actions Manager who owns corrective actions from:
events (e.g., occurrences, PAAA Nuclear Safety Rule); findings (e.g., internal or external audits); or self-assessments

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

  • Perform the causal analysis at the appropriate level of rigor.
  • 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).
  • 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.
Verify and Validate Corrective Action Effectiveness Managers Ensure that Members of the Workforce perform verification and validation of corrective actions for programs detailed in Table 1.
Develop Corrective Actions Members of the Workforce
  • Derive corrective actions from the causal analyses.
  • 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.” (See “Validation of Corrective Action Effectiveness” in the Corrective Action Guidance for more information.)
  • Follow the requirements at the 12857 website, "12857 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 Evidence of Completion Members of the Workforce
  • Ensure that the corrective action evidence is adequate.
  • Review programmatic requirements to ensure compliance.
  • Ensure evidence is in physical form; examples include:
    • 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 WebFileShare.
    • 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 12857 website, "12857 Internal Audit: ES&H, S&S, and IT Operations."

Table 1. Corrective Action Verification of Completion and Validation of Effectiveness Requirements

Program Verification of Completion Validation of Effectiveness
  Risk Level¹ Requirement Responsible Individual (for ensuring performance of verification) Requirement Responsible Individual (for ensuring performance of validation)
Occurrence Reporting (corrective action)          
OR levels OE, SC1, SCR High 100% independent verification Senior manager (in organization who owns the occurrence) 100% validation Senior manager (in organization who owns the occurrence)
SC2 Medium Sampling Senior manager (in organization who owns the occurrence) Optional Senior manager (in organization who owns the occurrence)
SC3, SC4, NOTE Low Optional Senior manager (in organization who owns the occurrence) Optional Senior Manager (in organization who owns the occurrence)
PAAA Nuclear Safety Rules – issues reported into NTS (corrective action)   100% verification Owning organization manager 100% validation Owning organization manager
PAAA Nuclear Safety Rules – issues reported into local system (corrective action)   100% verification Owning organization manager Recommended Owning organization manager
ES&H Issues Management (corrective action) High 100% independent verification Senior manager 100% validation Senior manager
Corrective Action Management Program (CAMP) (corrective action) High See CG100.6.6 and CG100.6.9      
Medium See CG100.6.6 and CG100.6.9      
Low See CG100.6.6 and CG100.6.9      
ES&H Quality, and Safeguards & Security Assessments, Department 12870 (corrective action) High Sampling 12857 Assessors Optional Division ES&H coordinator

 

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 PAAA office, MS 0361.

Implementing Tools

Guidance

  • Corrective Action Verification of Completion and Validation of Effectiveness Flowchart.

Form

  • Root Cause Analyst Qualification Form.

Websites

  • 12857 website.
  • Causal analysis.
  • Corrective Action Management Program (CAMP).
  • ESH Issues Management.

Tools

  • Corrective Action Tracking System (CATS) Application

 

Requirement Drivers (Prime Contract Baseline Directives)

DOE M 231.1-2 DOE O 414.1C DOE O 450.1A DOE 5480.19, Chg 2

Additional Drivers

  • 10 CFR 851, Worker Safety and Health Program.
  • DOE O 210.1, Chg. 2, Performance Indicators & Analysis of Operations Information, 9/27/95.
  • DOE N 231.1, Environment, Safety, and Health Reporting Notice, 1/15/02.
  • DOE G 450.4-1B, Integrated Safety Management System Guide.
  • Lockheed-Martin Corporate Energy, Environment Safety and Health, Corporate Functional Procedure No: ESH-10, Effective: 11/15/03, Revision: Original.

Training Requirements

Responsible Individual Required Recommended
Members of the Workforce Well-written corrective actions are critical for correcting problems and ensuring that they do not reoccur. Corporate causal analysis training provides guidance on developing corrective actions. See CG100.6.9 Conduct Root Cause Analysis and Extent of Condition Reviews, for training requirements. See Root Cause Analyst Qualification Form.

Related Processes and Procedures

Process

Procedures

  • CG100.6.6, Perform Corrective Actions.
  • CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews.
  • ESH100.4.FI.1, Perform ES&H Line Self-Assessment Activities.
  • ESH100.4.RPT.3, Report Occurrences.
  • ESH100.4.RPT.6, Identify, Report, and Correct Nuclear and Worker Safety Issues and Nonconformances.

Change Summary

Date Summary
12/02/2010

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.
06/16/2010

Administrative

Added

  • Link to CATS application
05/19/2010

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."