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Policy Area

ESH-Environment Safety & Health

Procedure Number

ESH100.4.FL.4

Procedure Title

Implement the Corrective Action Management Program for ES&H

Procedure Manager

BENDURE, ALBERT O.

Subject Matter Expert

  • Stephanie Oborny—Subject Matter Expert

Applicability, Exceptions, and Consequences

This corporate procedure applies to Members of the Workforce who are involved with corrective action plans (CAPs) and the Corrective Action Management Program (CAMP).

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 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 document describes the process for developing and managing ES&H corrective actions at Sandia National Laboratories facilities (e.g., SNL/NM, SNL/CA, and TTR).

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.FL.4 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.

Roles and Responsibilities

Activity Responsible Individual Required Action
Oversee Corrective Actions Responsible Manager (one level above finding corrective action record (CAR) owner)
  • Identify a proper Corrective Action Record (CAR) Owner.
  • Raise rejected ownership to the next level of management for final determination.
  • Address overdue corrective actions appropriately.
  • Brief the next level of management concerning late due dates of corrective actions.
  • Apply resources, if needed, to corrective actions.
  • Monitor implementation of corrective actions.
  • Serve as a verifier for each corrective action.
  • Review the progress of monthly status reports on opened corrective actions.
  • Attend SSO Change Control Board (CCB) meetings when changes occur to the CAP, if applicable.

Note: The CCB serves as a mechanism for finding owners to justify requests for changes to the Office of Independent Oversight (OIO) CAP or extensions for OIO corrective action due dates to the SSO/manager.  A letter with a justification will be submitted requesting the change or extension request by the appropriate CAP owner’s director.  For other audits, a CCB is not required; however, changes to CAPs or extensions to corrective action due dates, will be approved by the audit agency.
Process Corrective Actions Corrective Action Record (CAR) Owner
  • Acknowledge ownership.
  • Determine a risk rating (high, medium, and low) of the finding by using the risk grading criteria and CG100.6.1, Manage Risks.
  • Identify a corrective action report (CAR) delegate who ensures the submittal of corrective actions and updates into the Corporate Corrective Action Tracking System (CATS) in a timely manner.
  • Approve the CAP and any revisions as required.
  • Review monthly status reports on opened corrective actions.
  • Meet due dates for accountable corrective action(s).
  • Close out the corrective action after successfully completing verification.
  • Retain all documented evidence submitted for closure or forward documentation to ES&H Records Center.
Support Corrective Action Process Subject Matter Expert (SME), Team Member, or Solution Owner
  • Participate in corrective action development.
  • Generate and complete one or more of the corrective actions.
  • Ensure appropriate documented evidence submitted for closure of corrective actions.
  • Support a causal analysis, if required.
  • Analyze problems and causes necessitating a corrective action.

Notes:

  • The CAMP project lead managed CAMP, and the ES&H application manager managed CATS.
  • The ES&H Corrective Action Management Program (CAMP) is the corporate process for resolving ES&H findings assigned to all Sandia National Laboratories facilities because of surveys or audits.
  • The ES&H CAMP identifies the responsibilities for reporting, tracking, and closing designated corrective actions. CAMP sets requirements for performing corrective actions and includes the verification and validation review to ensure actions are completed.
  • CAMP defines requirements for implementing:
    • CG100.6.6, Perform Corrective Action.
    • CG100.6.9, Conduct Root Cause Analysis and Extent of Condition Reviews.
  • CAMP outlines the development, review, and approval process for ES&H-related corrective actions.
  • The CAMP description is in the 4100 Corrective Action Management Plan.
  • Also, see ESH100.4.FI.3, Implement and Manage Corrective Actions.

CAMP Process—Initiate

Steps Responsible Individual Required Action
1 Corrective Action Record (CAR) Owner (identified within the audit report) Use the risk grading criteria in CG100.6.1, Manage Risks, to determine the finding's risk rating of high, medium, or low.
Note:  The internal and external agencies provided audits, and the CAMP project lead managed CATS.

CAMP Process—Analyze

Steps Responsible Individual Required Action
1 Corrective Action Record (CAR) Owner Develop the Corrective Action Plan. 
2 Corrective Action Record (CAR) Owner

Assign the SME or team member(s) to generate corrective actions necessary to ensure effective closure of the finding or issue.

Notes:

  • The Corrective Action Record (CAR) Owner assigns a SME with causal analysis training and/or demonstrated experience to serve on the Corrective Action Team.
  • The size and composition of the team depends on the risk and may be composed of one SME for low-risk findings.
3 Corrective Action Team or SME Identify and document the causal code(s) at the A and B descriptor levels and develop corrective action(s) (see Table 1).

Table 1. Causal Codes

A Descriptor Identify Problem B Descriptor Corrective Action
A1 Design and Engineering Problem B1 Design input
    B2 Design output
    B3 Design documentation
    B4 Design installation verification
    B5 Operability of design and environment
A2 Equipment and Material Problem B1 Calibration for instruments
    B2 Periodic corrective maintenance
    B3 Inspection and testing
    B4 Material control
    B5 Procurement control
    B6 Defective, failed, or contaminated
A3 Human Performance B1 Skill-based error
    B2 Rule-based error
    B3 Knowledge-based error
    B4 Work practices
A4 Management Problem B1 Management methods
    B2 Resource management
    B3 Work organization and planning
    B4 Supervisory methods
    B5 Change management
A5 Communications B1 Written communications method of presentation
    B2 Written communication content
    B3 Written communication not used
    B4 Verbal communication
A6 Training Deficiency B1 No training provided
    B2 Training methods
    B3 Training material
A7 Other Problem B1 External phenomena
    B2 Radiological and hazardous material problem

CAMP Process—Develop

Steps Responsible Individual Required Action
1 Corrective Action Record (CAR) Owner and/or Team Document corrective actions to address causes of the deficiency and prevent recurrence.
2 Corrective Action Record (CAR) Owner and/or Team Develop and document corrective actions including owners and target completion dates.
3 Corrective Action Record (CAR) Owner and/or Team Obtain concurrence and approval of the corrective action plan from internal and external oversight, if necessary.

CAMP Process—Implement

Steps Responsible Individual Required Action
1 Corrective Action Record (CAR) Owner and/or Team Complete corrective actions in accordance with the plan schedule.
2 Corrective Action Record (CAR) Owner and/or Team Monitor and track completion of corrective actions. If necessary, revise the Corrective Action Plan, document the reason, and obtain concurrence (if required).

CAMP Process—Verify

Steps Responsible Individual Required Action
1 Verifier Ensure all the steps in the correction action plan have been completed and that documented evidence exists demonstrating that the corrective action(s) have occurred.
If… Then…
If corrective actions have been completed, Verification is complete.
If corrective actions have not been completed, Notify the corrective action owner (CAP) for further direction.

CAMP Process—Validate and Closeout

Steps Responsible Individual Required Action
1 Corrective Action Record (CAR) Owner

Ensure validation of corrective actions of all high-risk findings (from any source) within 1 year of completion, or as justified and documented in the Corrective Action Plan.

Note: Validation of medium- and low-risk findings is at the discretion of the corrective action owner.
2 Corrective Action Record (CAR) Owner Document evidence supporting validation results.
3 Corrective Action Record (CAR) Owner Determine whether deficiencies persist.
If… Then…
Corrective Action Record (CAR) Owner If evidence is not found that deficiencies persist, Close out the corrective action and document the completion of all planned actions.
If evidence is found that deficiencies persist, Document and inform management for further direction.

CAP and Closure Transmittals with Evidence Package

Activity Responsible Individual Required Action
Submit Office of Independent Oversight (OIO)Corrective Action Plans Corrective Action Record (CAR) Owner or SNL/POC
  • Prepare the transmittal letter for appropriate vice president signature, attach the CAP requesting CAP approval, and address the letter to the SSO/manager.
  • Send copies (without attachments) to the SSO assistant manager (ES&H/QA) and SSO/POC.
  • Submit other copies as deemed appropriate by CAP owners.

Note: Forward the file copy and attachments to the ES&H Records Center or file within the department.
Submit OIO Evidence Packages Corrective Action Record (CAR) Owner or SNL/POC
  • Submit an evidence package (see Table 2) for each OIO milestone upon each due date.
  • Prepare the transmittal letter for appropriate senior manager’s signature with evidence attached requesting closure of the OIO milestone and address the letter to the SSO assistant manager (ES&H/QA).
  • Send copies (without attachments) to the SSO/manager, SSO/deputy manager, and SSO/POC.
  • Submit other copies as deemed appropriate by CAP owners.

Note: Forward the file copy and attachments to the ES&H Records Center or file within the department.
Submit SSO Corrective Action Plans (Programmatic Assessment) Corrective Action Record (CAR) Owner or SNL/POC
  • Prepare the transmittal letter for appropriate senior manager’s signature, attach the CAP requesting CAP approval, and address the letter to the SSO assistant manager (ES&H/QA).
  • Send copies (without attachments) to the SSO/POC.
  • Submit other copies as deemed appropriate by CAP owners.

Note: Forward the file copy and attachments to the ES&H Records Center or file within the department.
Submit SSO Evidence Packages (Programmatic Assessment) Corrective Action Record (CAR) Owner or SNL/POC
  • Submit evidence package (see Table 2) upon completion of the last milestone on the CAP.
  • Prepare the transmittal letter for appropriate senior manager’s signature with evidence attached requesting closure of the milestone and address the letter to the SSO assistant manager (ES&H/QA).
  • Send copies (without attachments) to the SSO/POC.
  • Submit other copies as deemed appropriate by CAP owners.

Note: Forward the file copy and attachments to the ES&H Records Center or file within the department.
Submit Corrective Action Plans  and Evidence Packages for 12870 Corrective Actions Corrective Action Record (CAR) Owner or SNL/POC Follow 12870 process.
Submit Corrective Action Plans for Other Audit Agencies Corrective Action Record (CAR) Owner or SNL/POC Follow same process for submitting SSO Corrective Action Plans (Programmatic Assessments).
Submit Evidence Packages for Other Audit Agencies Corrective Action Record (CAR) Owner or SNL/POC Follow same process for submitting SSO Evidence Packages (Programmatic Assessments).

Table 2. ES&H Quality Review Checklist

Resolution of Findings Evidence Packages Verification Assessment
No. Criteria Yes
(√)		 No
(√)		 Comments and Examples
1 Did you provide evidence for each milestone?    
  • Check your deliverable and ensure your evidence reflects the commitment.
2 Was evidence sufficient to support completion of the milestone fully?    
  • Include updated CPRs, Operating Procedures, documented changes to ES&H Manual, copies of documented minutes of an ES&H Committee, etc.
3 Are the documents complete with required signatures?    
  • Ensure signatures for procedures requiring signature.
  • Ensure applicable personnel complete and sign required reading sign-off sheets.
4 Does the verification assessment provide a complete summary of all actions taken and evidence provided?    
  • Ensure there is coordination with the SSO/POC while conducting your verification assessment.
  • Secure the “buy-in” early in the verification process.
5 Was a performance test or other data gathering methodology* used where applicable and possible?    
  • Use other gathering methodologies whenever possible, in addition to the documentation review, to ensure effectiveness and to meet SSO’s expectations.

*Data gathering methodologies:

Interview
Documentation review
Knowledge-based test
Observation
Performance test
Other

Implementing Tools

Guidance

  • 4100 Corrective Action Management Plan.

Forms

  • SF2001-CAC, Corrective Action Change Request Form (Word file/Acrobat file).

Websites

  • DOE requirements provide the following programs with special ES&H corrective action processes:
  • ES&H, Quality, Safeguards & Security Audit (12870).
  • ES&H Occurrence Reporting Charter.
  • ES&H Radiological Process Improvement Reports (RPIRS).
  • Price-Anderson Amendments Act (PAAA).
  • ES&H Computerized Accident Incident Reporting System (CAIRS).

Requirement Drivers (Prime Contract Baseline Directives)

DOE O 226.1A DOE O 414.1C

Additional Drivers

  • DOE G 414.1-5, Corrective Action Program Guide.
  • 10 CFR 851, Worker Safety and Health Program.
  • Prime Contract Part I, Section H-3, “Contractor Assurance System.”

Training Requirements

Steps Responsible Individual Required Action
1 Corrective Action Record (CAR) Owner

Ensure validation of corrective actions of all high-risk findings (from any source) within 1 year of completion, or as justified and documented in the Corrective Action Plan.

Note: Validation of medium- and low-risk findings is at the discretion of the corrective action owner.
2 Corrective Action Record (CAR) Owner Document evidence supporting validation results.
3 Corrective Action Record (CAR) Owner Determine whether deficiencies persist.
If… Then…
Corrective Action Record (CAR) Owner If evidence is not found that deficiencies persist, Close out the corrective action and document the completion of all planned actions.
If evidence is found that deficiencies persist, Document and inform management for further direction.

 

Responsible Individual Required Recommended
Subject Matter Expert N/A Causal analysis training for serving on the Corrective Action Team.

Related Processes and Procedures

Process(es)

  • ESH100.4, Feedback and Improve.

Procedure(s)

  • ESH100.4.FI.3, Implement and Manage Corrective Actions.
  • CG100, Corporate Governance Policy.
  • CG100.5.3, Determine Need for Project, Facility, or Organization QA Program Document.
  • CG100.6.6, Perform Corrective Action.
  • CG100.6.2, Develop and Maintain the Integrated Assessment Schedule.
  • CG100.6.3, Perform Self-Assessments.
  • CG100.6.4, Perform Policy Area Self-Assessments.

Change Summary

Date Summary