There are three tasks associated with developing and implementing a process for identifying nonconformities and making corrections and taking corrective or preventive action:

• 4.5.1 Develop the process for corrective and preventive action
• 4.5.2 Define roles and responsibilities
• 4.5.3 Implement the process for corrective and preventive action

4.5.1 Develop the process for corrective and preventive action

Because most of the steps involved in corrective action and preventive action are the same, most organizations implement one process that addresses both. This process consists of the following elements:

1. Correct the current situation
2. Evaluate the magnitude and impact of the nonconformity
3. Determine the cause of the actual or potential nonconformity
4. Take action to eliminate the cause
5. Review the effectiveness of the action taken
6. Maintain records

The process for corrective and preventive action that you develop for your organization needs to take all of these elements into account. Most organizations use a corrective/preventive action form (usually electronic) to outline the steps in the process and capture the needed information. For an example, see the Corrective Action/Preventive Action Request Form.

If your organization has an integrated management system, consider using (or at least “harvesting from”) processes already in place. For example, your organization may already have corrective and preventive action process as part of another management system, such as an ISO 9001 quality management system or an ISO 14001 environmental management system.

1. Correct the current situation

When an existing nonconformity is detected, the first step is to take appropriate action to resolve the immediate situation. For example:

A facility has a compressed air system which is a large consumer of energy. The facility’s procedure states that the operating pressure set point for the compressed air system shall be 105 psig. The facility was found to be operating their compressor system at 115 psig. An example of correcting the current situation is to change the operating pressure back to 105 psig. But, remember to consider the effects on production before assuming the procedure is correct. The appropriate correction may be to change the procedure to state 115 psig.

This is called correction. Correction is necessary for existing nonconformities and does not apply to potential nonconformities.

2. Evaluate the magnitude and impact of the nonconformity

The next step is to determine the magnitude of the nonconformity and its impact on energy performance. This involves consideration of the extent of the nonconformity and its actual and potential effects on the:

• Energy objectives, targets and action plans,
• Significant energy uses,
• Energy efficiency of facilities, equipment, systems and processes,
• Existing or planned operational or maintenance controls, or
• Other energy sources or energy uses within the organization.

Based on this information, a decision is made as to whether the nonconformity or potential nonconformity should be subject to further review and investigation to ensure the situation is prevented from recurring (corrective action) or prevented from occurring in the future (preventive action). If so, the nonconformity is entered into the organization’s corrective and preventive action system.

3. Determine the cause of the actual or potential nonconformity

Once entered into the system (for an example, see the Corrective Action/Preventive Action Request Form), the nonconformity is reviewed to determine its cause. For example:

In the compressed air system example above, determining the cause consists of considering how and why the operating pressure was changed. Although any type of problem-solving process can be used, it can be helpful to apply the ‘5 Why’ concept to determine the cause of an existing or potential nonconformity. In this case, you may ask the following:

Question: Why was the operating pressure changed?

Answer: Because the operator thought it should be.

Question: Why did the operator think it should be changed?

Answer: Because the operator was experiencing problems at 105 psig that were not experienced at 115 psig.

Question: What problem was the operator experiencing?

Answer: A lack of sufficient pressure to actuate the press.

Question: What was the cause of the problem?

Answer: The pressure gauge was out of calibration and indicated incorrect pressures.

Question: Why was the pressure gauge out of calibration?

Answer: The calibration frequency was annual. The calibration history shows the gauge has been found to be out of calibration at each calibration for the past two years.

4. Take action to eliminate the cause

Next, you decide on and implement an appropriate course of action to eliminate the cause of the actual or potential nonconformity.

The actions taken to address a problem can sometimes result in the need to make other adjustments or changes to the EnMS. For example, if existing operational controls were modified as part of implementing a corrective action, then there may be a need to modify the associated EnMS documentation. The actions taken need to be appropriate to the extent of the problem and its impact on energy performance. Don’t spend $1000 on a $10 problem and vice-versa. For example:

In the compressed air system example, one action to eliminate the cause would be to increase the calibration frequency of the pressure gauges.

Once identified, a best practice in many organizations is determining whether the same corrective or preventive action is needed elsewhere, perhaps in another process, area or facility. A system-wide approach to problem identification and resolution such as this helps further a culture of proactive continual improvement. For most organizations, over time, this approach results in fewer nonconformities and negative audit findings. As an example:

In the example, you may decide that a look at the calibration frequency for all gauges is appropriate.

5. Review the effectiveness of the action taken

After the appropriate action is taken, a review is performed to determine if the action taken was effective. In other words, did the action taken eliminate the cause and result in the nonconformity not occurring or recurring? In some situations, it may be necessary to let a reasonable interval of time pass after the solution is implemented before the review for effectiveness is performed. Sometimes a solution needs time to work before its effectiveness can be fully evaluated. Returning to the compressed air system example:

The effectiveness review could consist of verifying that the calibration frequency was changed in the calibration system and then verify that the actual operating pressure is the same as that indicated in the procedure.

6. Maintain records

A Corrective Action/Preventive Action Request (CAR/PAR) Form, along with a CAR/PAR Tracking Log are commonly used to record and track the status of corrective and preventive actions. An Example CAR/PAR Tracking Log illustrates how a log sheet can be used to track actions to completion. Such log sheets can be particularly useful when it is time to compile data and other information on the status of corrective and preventive actions for management review (see Step 5.1).

4.5.2 Assign roles and responsibilities

The management representative is typically assigned responsibility for managing the corrective and preventive action system. However, this does not mean that the management representative is responsible for conducting the investigation and cause analysis and taking action. Rather, the management representative will assign the corrective or preventive action to the appropriate personnel and ensure that all required steps are followed and the appropriate records are maintained.

Most commonly, all employees are responsible for identifying actual and potential nonconformities in their work areas and for either informing the appropriate supervisory personnel or making an immediate correction.

Corrective and preventive actions are usually assigned to the manager of the department or area where the problem or potential problem exists. That manager may assign the corrective or preventive action for investigation and development of proposed actions to a specific individual or may assemble a team to address the problem. The follow-up that evaluates the effectiveness of the action(s) taken (i.e. did the solution work?) should be assigned to personnel who are independent from the area that was responsible for developing and implementing the corrective or preventive action.

Typically, timeframes are established for completion of the investigation and development of proposed action(s), and for implementation and the follow up for effectiveness. A 30-day timeframe is very common. However, it can be a good idea to allow for time extensions where appropriate justifications can be provided. For example, a solution that calls for capital investment in new equipment can take more time for full implementation.

4.5.3 Implement the process for corrective and preventive action

Like the other processes of the EnMS, implementation of the corrective and preventive action process involves putting the process into practice within your organization and ensuring that appropriate training is provided. Reviewing the steps to be followed, demonstrating the use of any required forms, and clearly communicating roles, responsibilities and expectations across the workforce supports conformance with the requirements of the corrective and preventive system.

These resources can help you develop your process for EnMS corrective and preventive action:

• Corrective Action/Preventive Action Request (CAR/PAR) Form
• Corrective Action/Preventive Action Request (CAR/PAR) Tracking Log
• Example Corrective Action/Preventive Action Request (CAR/PAR) Tracking Log

The following resources provide information needed to understand EnMS documentation and decide what documents and records are needed for your EnMS.

• Understanding EnMS Documentation
• EnMS Documentation Guidance Table
• Energy Manual Guidelines

The following resource is designed primarily for organizations that plan to seek third-party certification to ISO 50001-2011. It helps you understand how to check and use your EnMS records to demonstrate the implementation of the system (you are doing what you say), and the effectiveness of the system in generating the intended results (what you are doing is working).

• EnMS Records: Check and Use the Evidence