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NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

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					NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                   IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:     Audit/Assessment ID:                                        Audit/Assessment Date:
                                     MOC-Pacific EMS Self-Declaration
 ISO 4.3.1 & related EO 13148 requirements                                                       05/17-18/05
                                     1 of 14

 Details of Non-Conformance
 ISO Finding: Requirement to review worksheets on an annual basis could not be conformed through updated
 document controls, i.e. dates not changed to reflect reviews conducted in 03 – 05. Use of recently acquired
 document control program is expected to improve current conditions. It is unclear the status of Hotel Ship in
 EMS, activities can have potential impact while docked, assessment of Task Order actions to install temporary
 boiler on pier may have prevented emergency action associated with spill.

 EO Finding: Full life cycle assessments not covered through activity/impact assessment. Cost accounting
 limited to mgmt cost of impact.

 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2         (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action
 ISO Finding: MOC has purchased software to manage documents for document control. Document reviews are set
 and reminders are sent via e-mail and as the document is updated revision dates are included. The Hotel Ship
 (Deactivate vessel) would have the same impacts as a normal vessel berthed at the marine center. The boiler was
 used by a active vessel. Contractor personnel did not inspect the secondary containment to ensure all plugs were in
 placed before testing boiler.

 EO Finding: DOC Commerce Acquisition Manual section 1323.70 DOC Affirmative Procurement Program was
 issued in Dec 2005. This document formally establishes the DOC’s Affirmative Procurement Program (APP) for
 EPA designated recycled content products and provides agency wide guidance on implementing an effective
 program. The document meets the requirements for RCRA Section 6002, E.O. 13101, EPA Comprehensive
 Procurement Guidelines, Office of Federal Procurement Policy, Policy Letter 92-4, and the FAR.

 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                            TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken. Documents are being reviewed and maintained via the internet and uploaded
 to EMS website. An Environmental Alert #2006-0001 – Affirmative Procurement Program was sent out to Offices
 within DOC. The alert is posted on the MOC Web site and SECO website.
 Signature and Date: James Schell 6/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                   IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.3.2                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              2 of 14
 Details of Non-Conformance
 ISO Finding: Requirements of applicable requirements are integrated within corresponding SOP, but exactly
 how the requirements are identified within a broad legal requirement and how these requirements are
 integrated within an applicable SOP is not specifically described. For example, the NECSAS compliance
 assessment may be considered as a check against the inclusion of applicable requirements into relevant SOPs.




 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2         (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action




 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                            TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken. SECO office revised the NOAA Standards




 Signature and Date: James Schell           6/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                 IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.3.3                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              3 of 14
 Details of Non-Conformance

 ISO Finding: Objectives not reviewed, updated or developed to adequately cover current
 improvement requirements in conformance with environmental policy and conditions at
 facility, i.e. minimize natural resource use - dripping water pipes requiring new fittings;
 best means to manage temporary workers to ensure awareness and management of environmental impacts.


 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2         (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action




 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
Confirmation that the action was taken.
Objectives were reviewed and leaking water were repaired and facility manager provide awareness training to
temporary employees.




Signature and Date: James Schell         June 3, 2005




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                  IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.4.1                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              4 of 14
 Details of Non-Conformance

 ISO Finding: Current Performance Plans must be reviewed to ensure all critical EMS responsibilities are
 identified, i.e. maintenance of SOPs and Management Review responsibilities.




 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2        (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action




 Action approved by:                                                           Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                            TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
Confirmation that the action was taken. Assistance from Supervisors is required to complete this. Facility personnel
have these in the performance standards.




Signature and Date: James Schell                    9/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                  IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:     Audit/Assessment ID:                                        Audit/Assessment Date:
                                     MOC-Pacific EMS Self-Declaration
 ISO 4.4.2 & related EO 13148 requirements                                                       05/17-18/05
                                     5 of 14
 Details of Non-Conformance

 ISO Finding: Means to assess (at time of training or through for example OJT) competency/assurance of
 awareness not formally established. Awareness through interviews with staff at time of audit indicate: The
 importance of conformance to and potential consequences of departure from system requirements not fully
 accepted by staff, i.e. awareness of items on SOP not being followed yet no action to amend practice or SOP as
 applicable.

 EO Finding: EO 13148 awareness identified in training program content (Slides). Awareness limited to
 requirement to develop an EMS, goals associated with EO not specifically identified. Procurement staff
 training not identified on training matrix, but electronic based training provided by NOAA Bank Card
 Training and DOC Acquisition Training. Records (or some means o assure worker training) associated with
 electronic training should be developed.

 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1        3 (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action
 Increased training will be developed using NOAA;s new training web site. Additional training will be accomplished
 with the development of power point presentations, increased e-mails to employees. Training Matrix will be
 reviewed and adjusted to meet any new requirements. Once a review is completed the Matrix will be reviewed
 yearly.

 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                            TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.
 Increase training was accomplished by class room, required training by NOAA Finance Office Administration
 (NFA) for bank card purchases. Training records are maintained by NFA. If training is completed an e-mail is sent
 to the supervisor of the employee that training has not been accomplished. If training is not completed the credit card
 is revolted. Employees can print out a certificate of completion for their records and forwarded to their approving
 offical.

 Signature and Date: James Schell                   7/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION
STEP 1
                                                  IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.4.3                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              6 of 14
 Details of Non-Conformance

 ISO Finding: Requirement to maintain external communications not fully followed, i.e. communications
 associated with closure of NOI not available.


 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1       3 (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action
 Increase training for MOC personnel on Operating Procedures will be increase for external communications
 requirements.




 Action approved by:                                                           Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                            TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.
 Personnel have been instructed to provide copies of all NOI or NOV to MOC SECO to maintain records of closing of
 NOI or NOVs.




 Signature and Date: James Schell                      7-05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                  IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.4.4                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              7 of 14
 Details of Non-Conformance

 ISO Finding: MOCDOCs not adequately referenced within EMS system requirements, i.e. SOPs do not
  reference links inherent to management of environmental impact, for example, Haz mat instruction and
  hotlink to MOCDOC 15, Fleet Environmental Compliance #07, may be added to EM.WS.2000.7,
 draft Vessel SOPs do not consistently reference MOCDOCs, and ships required documentation.




 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1        3 (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action
 The MOCDOC documents are referenced in the Compliance Assurance Plan regulatory requirements. Personnel
 can located the MOCDOC’s documents using the CAP reference number located on each operating procedure. To
 help marine center personnel locate document references in the SOP’s links will be located at the reference
 documents.

 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                            TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.
 MCODOCs was reference in the legal requirements and the vessels are still in development. The vessels SOPs are
 not completed and follow MOC SOPs at this time.




 Signature and Date:       James Schell                8/08




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                  IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.4.5                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              8 of 14
 Details of Non-Conformance

 ISO Finding: Technical services associated with aspects of intranet controlled documents not maintained, i.e.
 frequent requirement to log in, some links indicate “unavailable”.




 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2         (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                               CORRECTIVE AND PREVENTIVE ACTION
                                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action




 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.

 Requested that the links be corrected and maintained by the SECO contractor.



 Signature and Date:        James Schell               6/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                                  IDENTIFY THE NON-CONFORMANCE
                                 COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:      Audit/Assessment ID:                      Audit/Assessment Date:
 ISO 4.4.6 & related EO 13148         MOC-Pacific EMS Self-Declaration          05/17-18/05
 requirements                         9 of 14
 Details of Non-Conformance
 ISO Finding: Assessment of development, maintenance and conformance to Operational controls at time of
 audit indicate:
      2004.1 not followed by MED, i.e. clear oversight/monitoring responsibilities of contractors not
          established.
      3210 Inspections and log for OWS not developed or routinely performed.
      3223 Asbestos remediation not reflected in a revised SOP
      3004 portable (small) secondary container not used along pier as indicated in SOP.
      Form 5.16 does not include inspections associated with asbestos.
      3222 Parking lot maintenance of catch basins not performed, i.e. 2 drains do not have required
          absorbent pads
      3212 Parts Washer Work instruction described filter mgmt but there is no evidence of filter change.
          (Filter maintenance is being conducted by outside contractor.)
      3203 Aerosolv WI does not provide instruction on how to determine when 20 gallons of waste has
          been accumulated.
      3204 Spill clean-up SOP not followed, i.e. Spill at forklift storage area not identified or cleaned up at
          time of facility walkthrough. WI states spill kit must be near charging areas, note - kit was moved
          adjacent to area during audit.
      Health Services: Development and retention of all legally required documents not specified on SOP,
          i.e. narcotic and expired pharmaceutical waste record of shipment kept for 2 years per FDA; (record
          is kept). (Requirement for Blood Borne Pathogen Program for vessels remains open.) The
          requirement to maintain chemical inventory may need to be reevaluated due to frequent turnover.
      Interviewee was able to locate EM.WS.3202 and access the Fleet Medical Policy on MOCDOCs (#13).
      Movement of oil drums using secondary transport pallet not identified in applicable SOP.
      At Contractor dock used oil/solvent in flammable storage building not stored in secondary
          containment, 2 tanks of CH2FCF3 not secured (located outside flammable storage building)
      Hotel Ship emergency eyewash empty, fire extinguisher not tagged, 3 55 gallon DTE stored over
          secondary containment that was full of water.
      Routine facility walkthroughs by staff do not reflect timely clean-up of trash/waste, i.e. metal/PVC in
          water at contractors dock area.
 EO Finding: Credit card purchase process does not indicate a requirement to limit toxic chemical
 acquisition, i.e. use of Approved List of Chemicals
 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one N/A)
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 ISO 14001  EO 13148             (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire

 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

STEP 2
                                        CORRECTIVE AND PREVENTIVE ACTION
                              TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action
 SECO will review operating procedures with the respective departments to determine what changes are needed.
 Once the review is completed, The EMS team will review and approved any changes. Increased awareness training
 will be accomplished for department personnel on understanding operating procedures.

 Action approved by:                                                    Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.
 ECO and facilities worked together to ensure the respected Sop are followed and contractor provide the guidance and
 Training on expectations while working onsite.



 Signature and Date:       James Schell                 9/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                           IDENTIFY THE NON-CONFORMANCE
                           COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.4.7                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              10 of 14
 Details of Non-Conformance

 ISO Finding: Emergency Response plan not updated since 01. Revisions required, i.e. identification of
 current staff. There is no evidence that the Plan has been reviewed/revised after an incident, i.e. after oil spills.




 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1        3 (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                        CORRECTIVE AND PREVENTIVE ACTION
                              TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action
 Emergency Plan will be updated by July 1, 2005. New management personnel will be arriving at MOC-P within the
 new month or so. The plan will be updated as needed electronically on MOC safety and Environmental web site for
 ease instead of hard copy.

 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken. All Plans were updated and instead of using names positions were sue to help
 reduce work load of revising plans. Plans were added as part of the new software with a reminder for review on an
 annual basis.



 Signature and Date: James Schell                     6/05




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                           IDENTIFY THE NON-CONFORMANCE
                           COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.5.1 & required EO 13148                MOC-Pacific EMS Self-Declaration                   05/17-18/05
 requirements                                 11 of 14
 Details of Non-Conformance

 ISO Finding: All performance reporting required for DOC, PMC and RCRA not specifically identified in
 EPP format. Note: Reporting requirements were met and reported.


 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2         (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                        CORRECTIVE AND PREVENTIVE ACTION
                              TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action




 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.
 Reports sent to DOC and etc is completed yearly via an e-mail request from headquarters. The completed reports are
 then retain at the MOC SECO office for future reference and review.




 Signature and Date: James Schell            1/06




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                           IDENTIFY THE NON-CONFORMANCE
                           COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.5.2 & required EO 13148                MOC-Pacific EMS Self-Declaration                   05/17-18/05
 requirements                                 12 of 14
 Details of Non-Conformance

 ISO Finding: Assessment of the procedure and the audit conducted at MOC in 04 indicate:
 Audit procedures (steps followed) do not specify the requirement for contractors to consider the
 facility questionnaire prior to the on-site assessment and for the development of the state
 supplemental checklist. Requirement to maintain audit records ( i.e. completed audit checklists)
 is not specified (and request to provide completed checklist not met), proof of closure not identified
 on non-conformance which may be related to unclear status of non-conformance as open or closed.

 EO Finding: Three year audit schedule is not maintained, i.e. NECSAS audits are scheduled every four years.
 There is no evidence that contractor activities are assessed for compliance to applicable regulatory
 requirements.
 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1        3 (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                        CORRECTIVE AND PREVENTIVE ACTION
                              TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action
 The NECSAS Policy is under review and revisions. This is an SECO headquarters’ issue and will be address by
 NECSAS program manager.

 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken. The NECSAS program is under review with new requirements to meet the
 changing reporting requirements and provide access to facilities to review their audits and questionnaires.



 Signature and Date: James Schell             6/06




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                           IDENTIFY THE NON-CONFORMANCE
                           COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.5.5                                    MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              13 of 14
 Details of Non-Conformance

 ISO Finding: Audit program and identification of “tiers” must be revised to reflect actual conditions, for
 example the Self-Declaration Audit may be considered a key component of the process.


 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2         (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                        CORRECTIVE AND PREVENTIVE ACTION
                              TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action




 Action approved by:                                                          Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.
 NOAA SECO and DOC developed an audit process using the ISO 14001 standards for audits.




 Signature and Date: James Schell                       6/06




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO
NOAA - MOC                  EMS                 Date issues & revised: 8-12-03 Revised 11-11-04 3/5/05
                         FORM 014.01            Reference: EMS 014

NON-CONFORMANCE CORRECTIVE AND PREVENTIVE ACTION

STEP 1
                                           IDENTIFY THE NON-CONFORMANCE
                           COMPLETED BY AUDITOR OR PERSON SUGGESTING NECESSARY ACTION
 EMS Element or area of Concern:              Audit/Assessment ID:                               Audit/Assessment Date:
 ISO 4.6                                      MOC-Pacific EMS Self-Declaration                   05/17-18/05
                                              14 of 14
 Details of Non-Conformance

 ISO Finding: EMS 015 Actions not modified to reflect changes in Management Review process.
 Results/outcome (beyond agenda item) of Management Reviews should be clearly identified and documented.
 Attendance should be emphasized and copies of minutes sent to those who could not attend.



 Category of Non-Conformance identified through Self-Assessment: Housekeeping (H), Serious Condition (SC) (circle one) N/A
 N/A
 Category of non-conformance found through EMS Audit: Significance 0 1 2         (circle one)

 Relevant supporting information or requirements (reference documents or records associated with action)
 EMS Self-Declaration Assessment Questionnaire


 Action submitted to: J. Schell, EMS Representative                                                   Date: 05/18/05

STEP 2
                                        CORRECTIVE AND PREVENTIVE ACTION
                              TO BE COMPLETED BY PERSON RESPONSIBLE FOR TAKING ACTION
 Proposed Corrective and Preventive Action




 Action approved by:                                                           Date:
 (Auditor or EMS Representative must approve suggested action)
STEP 3
 CORRECTIVE AND PREVENTIVE ACTION APPROVAL AND CLOSURE OF NON-CONFORMANCE
                     TO BE COMPLETED BY PERSON RESPONSIBLE FOR CLOSING NON-CONFORMANCE
 Confirmation that the action was taken.
 Minutes is maintained and reports are completed during staff meetings




 Signature and Date:           James Schell                        8/06




"NOT CONTROLLED" UNLESS VIEWED VIA NOAA INTRANET OR DISTRIBUTED HARDCOPY BY MOC ECO