formerly University of Missouri-Rolla
CORRECTIVE AND PREVENTIVE ACTION PROCEDURE

Purpose and Application

  1. To establish a process for taking corrective action when non-conformances to Missouri S&T’s Environmental Management System (EMS) are identified, for taking preventive actions when potential non-conformances are identified, and for taking action when opportunities to improve the EMS are identified.
  2. This procedure applies to all University operations and activities that occur on the Rolla campus and associated sites.

Definitions

  1. Corrective Action - Actions taken to correct a known non-conformance with the Environmental Management System. This term is used throughout the procedure and includes corrective action, preventive action, and continuous improvement action.
  2. Preventive Action - Action taken to prevent a potential non-conformance with the Environmental Management System.
  3. Root Cause Analysis – A process improvement and error / defect prevention tool that examines the individual processes within a system and uses a series of “why” questions to determine the reasons for variations.
  4. Continuous Improvement - Action taken to improve the EMS.
  5. Unusual Occurrence - Classification for non-conformance believed to be freak occurrences and no action is required.
  6. Champion - The departmental point of contact for corrective and preventive action issues.

Roles and Responsibility

  1. All departments are responsible for taking timely corrective action for issues found during routine reviews of their areas. Departments will have 3 days in which to correct the non-conformance or respond formally to the EMS Coordinator that an action plan for correction has been approved.
  2. The EMS Coordinator is responsible for notifying champions and initiating corrective actions using the Missouri S&T corrective action database.
  3. The EMS Coordinator is responsible for tracking completion of corrective actions, scheduling reviews for the effectiveness of corrective actions, and preparing information on corrective actions for top management to review.
  4. Champions are responsible for assigning the appropriate persons within the department to take timely corrective action when non-conformances or the potential for non-conformances are identified.
  5. The person(s) assigned to take corrective action in the department is responsible for taking the action, documenting the action and providing this information to the champion for review.
  6. Champions are responsible for notifying the EMS Coordinator when the corrective actions have been completed.
  7. The EMS Coordinator is responsible for verifying that corrective actions are taken and completed.

Procedure

Departments must immediately address non-conformances that are easily corrected. Non-conformities that require a more thorough corrective action will be corrected according to the following procedure:

Procedure for Corrective Actions

  1. Following an internal / external review of the EMS or any other instance that requires a corrective action, the EMS Coordinator will enter the non-conformance into the corrective action database. There is a corrective action form on the EMS/EHS website that allows any Missouri S&T personnel to enter a corrective action request. The corrective action form should be sent to the EMS Coordinator to be entered into the corrective action database.
  2. Once a corrective action is received by the EMS Coordinator the information is entered into the corrective action database. A corrective action request (CAR) form is generated. The CAR is sent to the appropriate departmental Champion for review and assignment of responsibility.
  3. The Champion assigns a team leader and team members. The team leader and or team members correct the non-conformance and send the information to the EMS Coordinator.
  4. The Champion will perform a root cause analysis to determine why non-conformance occurred and what steps can be taken to ensure the issue does not reoccur. The findings from the root cause analysis will be communicated to the EMS Coordinator.
  5. The EMS Coordinator updates the corrective action database with the information provided by the Champion.
  6. The EMS Coordinator schedules and performs a verification audit.
  7. If not verified, the EMS Coordinator will issue a new CAR using the corrective action database and the procedure is repeated.
  8. If verified, the EMS Coordinator updates the Corrective Action Database and the issue is closed. No further action required.

Corrective Action Request Form

Root Cause Analysis Form

Procedure for Preventive Action

  1. A preventive action is sent out to the campus community when a repetitive noncompliance occurs. The preventive action is a tool used to bring awareness to the campus community to avoid other instances of the same noncompliance occurring.

If verified, the EMS Coordinator updates the database and the issue is closed. No further action required.

    Objective Evidence

Record / Form Responsibility Location Retention
Corrective Action Database EMS Coordinator EHS 3 Years