Element 14: Non-conformance: Preventive & Corrective Action Procedures for Investigation and Taking Corrective Action for Non-conformances The Encina Wastewater Authority (EWA) must develop and implement a procedure to: Investigate any noncompliance with applicable regulatory requirements and/or non-conformance with internal EMS procedures identified during routine monitoring and measurement or periodic internal EMS audits: Identify the cause and take actions to correct the non-conformance; and Document the necessary corrective actions taken to prevent a recurrence. Corrective Action Plans for Non-conformances Corrective action plans must be developed to address non-conformances identified during routine monitoring and measurement. Such plans may be as brief as is appropriate to the situation, but at a minimum, identify the non-conformance, the root cause(s) and the corrective action being taken. The corrective action plan must identify changes to policies, programs, plans, operational controls and monitoring/measurement procedures to prevent future non-conformances. Corrective Action Plans for EMS Audits Formal corrective action plans must be established to address the findings of internal EMS Audits under Element 16, and EMS verification audits conducted by third parties. The corrective action plan must be documented, and describe what actions will be taken to address the audit findings, the individual(s) responsible, the estimated completion date and required resources to develop and implement corrective and preventative action. Progress in completing the corrective actions must be tracked and periodically updated to reflect completion. The corrective action plan shall include recommended changes to policies, programs, plans, operational controls and monitoring/measurement procedures to prevent future non-conformances. These changes must be documented in the corrective action plan, and in the EMS Manual and other relevant EMS documentation. ELEMENT 14 DOCUMENT: Objective Definitions Summary Procedures Documentation & Responsibility Checklist Corrective Action Notice (CAN)