NONCONFORMITY, CORRECTIVE ACTION AND PREVENTIVE ACTION

Approval: Tech. Svcs. Dept. Original Issue Date: 01/01/2007 No. ENV-11

Owner: Tech. Svcs. Dept. Revision Date: 7/2/13 Page: 1 of 3

PURPOSE: The purpose of this procedure is for implementing corrective and preventive
actions to address actual and potential nonconformities as well as taking any
actions to mitigate any related impacts. This procedure addresses the
requirements of ISO 14001, 4.5.3.

SCOPE: This procedure applies to nonconformities related to LCSWMA’s EMS;

including contractors or vendors working on behalf of LCSWMA.

REFERENCES: ENV-05 Communication

ENV-05A Environmental Communications Log Form
ENV-08 Emergency Preparedness and Response
ENV-09 Monitoring and Measurement
ENV-10 Evaluation of Compliance
ENV-13 Internal EMS Audit
ENV-11A Nonconformance Report (NCR) Form
ENV-11B Findings Log

DEFINITIONS:

1. Procedure
1.1 Potential and actual nonconformities are identified and reported to the
Technical Services Department following the communication procedure (ENV-
05). Potential and actual nonconformities can be identified through:
• Internal or external communications (ENV-05)
• Emergency Preparedness and Response (ENV-08)
• Monitoring and measurement activities (ENV-09)
• Regulatory compliance evaluations (ENV-10)
• Internal EMS audits (ENV-13)
• Third Party audits
• General observations related to possible corrective or preventive
actions
• Regulatory inspections

G:\LevelIIDocs\ENV-11, Nonconformity Corrective and Preventive Actions.doc

Description of Revision(s): 1/2/2008; 1/23/08. 5/12/08; insert Section 1.3 related to the Findings Log (ENV-11B) for tracking
actions for findings graded “O” (observation) and “RC” (Requires Correction); 6/3/10

“K” or “G” drive as controlled documents; 7/14/10- Tech. Svcs. Dept.; 8/17/10 –job titles;11/26/10 - 1.7; 1/31/12 – RCA; 7/2/13- #1.8
 NONCONFORMITY, CORRECTIVE ACTION AND PREVENTIVE ACTION

Approval: Tech. Svcs. Dept. Original Issue Date: 01/01/2007 No. ENV-11

Owner: Tech. Svcs. Dept. Revision Date: 7/2/13 Page: 2 of 3

1.2 The Technical Services Department reviews the reported potential

nonconformity and determines the need to initiate a Nonconformance Report
(NCR) Form (ENV-11A) and/or any immediate actions to mitigate related
impacts. The Non-Conformance Report Form will be initiated for internal
EMS audit findings graded as an Improvement (I) or Nonconformance (N)
and third party audit findings graded as either a Major or Minor
Nonconformance.

1.3 The actions taken to address findings graded as an Observations (O) or

Requires Correction (RC) during the internal and third party audits, and the
Table of Findings and Recommendations from Environmental Compliance
Assessment Reports are tracked using the Findings Log (ENV-11B). The
Technical Services Department maintains the Findings Log.

1.4 The Technical Services Department completes a NCR form and assigns a
sequential NCR number. The NCR is issued to the Facility Manager in the
area in which the potential or actual nonconformance was identified.

1.5 The Technical Services Department determines the corrective action, taking
into consideration causes and preventive actions that need to be taken.
Depending on the type of nonconformance, an additional root cause analysis
may be necessary to determine the source of the problem and to prevent the
problem from reoccurring in the future. This information is entered onto the
NCR along with a target date for completion. Appropriate Senior
Management and Facility Manager(s) may assist with determining
corrective/preventive actions, as needed.

1.6 The Facility Manager in the area(s) in which the NCR was issued is
responsible for tracking the corrective actions and for ensuring their
completion.

1.7 The Technical Services Department reviews the completed corrective and/or
preventive action for effectiveness prior to its closure. The review occurs on,
at least, a semiannual basis. During the review, the NCRs are analyzed to
determine if there are potential trends developing which would require
modifications to procedures.

1.8 The Technical Services Department will work with any responsible party to
determine if further analysis or follow-up is needed after the review of the
 NONCONFORMITY, CORRECTIVE ACTION AND PREVENTIVE ACTION

Approval: Tech. Svcs. Dept. Original Issue Date: 01/01/2007 No. ENV-11

Owner: Tech. Svcs. Dept. Revision Date: 7/2/13 Page: 3 of 3

NCR; if more is needed, an Environmental Communications Log Form (ENV-

05A) may be used to provide further documentation.

2. Responsibilities

2.1 Technical Services Department

The Senior Manager, Technical Services and/or Environmental Compliance
Manager review the reported potential nonconformance and determine the
need to initiate a NCR and complete the NCR form, if necessary; and
maintains the Findings Log. The Technical Services Department assists with
determining the corrective action, taking into consideration root causes and
preventive actions that need to be taken, and reviews the completed
corrective/preventive action for effectiveness prior to its closure.

2.2 Senior Management

The Senior Management, as needed, assists with determining the corrective
action, taking into consideration root causes and preventive actions that need
to be taken, and reviews the completed corrective/preventive action for
effectiveness prior to its closure.

2.3 Facility Manager

The Facility Manager in the area(s) in which the corrective action is issued, is
responsible for assisting the Technical Services Department, as needed, in
determining the corrective/preventive action to be implemented. Additionally,
the Facility Manager is responsible for tracking the corrective actions and for
ensuring their completion.

3. Training
3.1 Training needs will be identified and conducted, if required, in accordance
with ENV-04.

4. Records
4.1 Nonconformance Report (NCR) Form (ENV-11A)
4.2 Findings Log (ENV-11B)