Purpose and Application

1. The purpose of this procedure is to establish a process for taking corrective action when non-conformances to the University's 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 and Scope

1. Corrective Action: Actions taken to correct a known nonconformance with the Environmental Management System
2. Preventive Action: Action taken to prevent a nonconformance with the Environmental Management System.
3. Continuous Improvement: Action taken when the EMS is performing to requirements, to improve the EMS.
4. Corrective Action (C/A): This term is used throughout the procedure and includes corrective action, preventive action, and continuous improvement action.
5. Formal Corrective Action: Actions taken when a nonconformance, or potential nonconformance is identified and the cause and/or corrective action is not known.
6. Quick Fix: Actions taken for a nonconformance or potential nonconformance is identified and the cause and/or corrective action are known, and the magnitude of the nonconformance and/or risk to the organization is minimal.
7. Achieve: Classification for nonconformance's believed to be freak occurrences and no action is required at this time.
8. 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. If issues require additional assistance, departments are responsible for requesting formal corrective action from the EMS Coordinator. 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 issued to top management for 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, verifying that corrective actions are taken, and for updating the EMS Coordinator on actions taken.
  5. The persons assigned to take corrective action in the departments are responsible for taking corrective action, recording the action that has been taken on the CAR form, and for providing this information to the champion for review.

Procedure
When departments identify non-conformances that can be corrected simply, they must correct the nonconformance. Non-conformities identified during internal audits, external audits, emergency preparedness drills or events, and those issues identified by a department that require more formal corrective action will be corrected according to the following procedure steps:

Procedure Steps for "Quick Fix" Corrective Actions

• Following an internal review of the EMS, external audit of the EMS, emergency response, drill, compliance inspection, or any other instance that requires corrective or preventive action: The EMS Coordinator (or other Missouri S&T personnel) enters a request for "quick fix" corrective action using the Corrective Action Database. (OR: Missouri S&T Personnel may request corrective action using the Corrective Action Request form found on the EHS or EMS web sites. Form is completed by a department and sent to the EMS Coordinator).
• The Corrective Action Request (CAR) is sent to the appropriate departmental Champion for review and assignment of responsibility.
• The Champion assigned a person responsible to correct the issue and designated an estimated completion date. Champion sends this information to the EMS Coordinator.
• EMS Coordinator updates the Corrective Action Database with the information provided by the Champion.
• The Champion notifies the EMS Coordinator when the corrective or preventive action has been completed.
• EMS Coordinator updates the Corrective Action Database with the information provided by the Champion.
• EMS Coordinator schedules verification audit.
• If not verified, EMS Coordinator issues a CAR using the Corrective Action Database and the procedure is repeated. (At this point, the EMS Coordinator may consult with the Champion to determine if "formal" corrective action is necessary.)
• If verified, EMS Coordinator updates Corrective Action Database and the issue is closed. No further action required.
  Corrective Action Request Form

• Following an internal review of the EMS, external audit of the EMS, emergency response, drill, compliance inspection, or any other instance that requires corrective or preventive action: The EMS Coordinator (or other Missouri S&T personnel) enters a request for "formal" corrective action using the Corrective Action Database. (OR: Missouri S&T Personnel may request corrective action using the Corrective Action Request form found on the EHS or EMS web sites. Form is completed by a department and sent to the EMS Coordinator).
• The formal Corrective Action Request (CAR) is sent to the appropriate departmental Champion for review and assignment of responsibility.
• The Champion assigned a team leader and team members. Champion send this information to the EMS Coordinator.
• EMS Coordinator updates the Corrective Action Database with the information provided by the Champion.
• Team leader and team members complete steps 2 through 7 of the corrective action, and provide this information to the EMS Coordinator.
• EMS Coordinator updates the Corrective Action Database with the information provided by the Champion.
• EMS Coordinator schedules verification audit.
• If not verified, EMS Coordinator issues a CAR using the Corrective Action Database and the procedure is repeated.
• If verified, EMS Coordinator updates Corrective Action Database and the issue is closed. No further action required.
  
  Corrective Action Request Form

Objective Evidence