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Marines


Checking and Corrective Action - EMS Element 12-16
Checking and Corrective Action page

The Marine Corps EMS emphasizes continual improvement through effective policy, planning, implementation, checking and preventive or corrective action, and management review.  This component ensures that the EMS actively measures and monitors performance, inspects for compliance, corrects deficiencies to address the root cause of problems, maintains proper records, and properly implements EMS requirements.  The ECE program satisfies the checking and preventive or corrective action component of the Marine Corps EMS:

EMS Element 12: Monitoring and Measurement

Element Purpose & Overview

MCAS Miramar maintains procedures to monitor and measure the installation’s environmental practices and associated resources that can have a significant environmental impact.  They document the information to monitor performance as well as for tracking progress toward meeting their environmental objectives and targets.

References:

Environmental Management Procedure

MCAS Miramar monitors their conformance of their EMS and the status of their compliance with regulatory and other requirements through annual self-audits and the Marine Corps ECE Program (see Element 13).  Noncompliance is managed in accordance with the problem-solving EMS element (see Element 14).  Findings as a result of such audits are entered, tracked and monitored using the current Marine Corps enterprise management system.

Monitoring and measuring requiring specialized testing equipment is performed by contractors.  Maintenance, calibration and associated calibration/testing records of all testing equipment is performed and maintained by the applicable contractor IAW provisions established by MCO 5090.2.

EMS Element 13: Evaluation of Compliance

Element Purpose & Overview

Evaluation of compliance is accomplished through the Marine Corps ECE Program.  Miramar evaluates all commands, units, and tenants for compliance with applicable laws, regulations, and directives at least annually, and ensures that all other installation activities comply with the same.  Miramar implements a compliance self-audit plan that is consistent with MCO 5090.2 (JUN 2018) Chapter 4.  Annually, a self-audit plan is released that identifies a monthly schedule of units/commands/tenants to be evaluated throughout the year.  

References:
 

Environmental Management Procedure

Miramar evaluates compliance according to the procedures established in Chapter 4 of MCO 5090.2 (JUN 2018)

Audit findings that require corrective action are managed in accordance with the problem-solving EMS Element 14.

Audit reports, including audit findings and the results of related corrective action, are reviewed by the installation's EMS Team throughout the year and again while performing management review.  Records of these periodic self-audits are maintained in accordance with Element 15, Control of Records.  The archived electronic copies of previous annual self-audits are maintained on local hard drives held by the Compliance Division.

On an annual basis, MCAS Miramar evaluates all commands, units, and tenants (including contractors and outlease activities) for compliance with applicable laws, regulations, and directives.

MCAS Miramar prepares and implements a compliance self-audit plan that describes its compliance self-audit program required under MCO 5090.2 (JUN 2018).  The inspection/audit criteria are also entered and evaluated through the installation's and 3rd MAW CGIP.

​​​​​​2019 Audit Plan and Checklists

Any findings during an Annual Self-Audit are reported back to the EMD using the format in the Corrective Action Plan (sample). Previous audit results and unit/command Corrective Action Plans (CAPs) are held in accordance with Element 15.  Once a unit reports corrective actions, the Compliance Auditor assigned to that unit will verify the corrective actions have been completed.  If further action is required by the unit for further compliance/conformance resolution, the Compliance Auditor assigned to that unit will personally work with the unit until resolution is accomplished.  Follow-up audits by the Compliance Department are part of the normal procedure to ensure continued compliance.

EMS conformance problems are identified during the evaluation of compliance, and corrective and preventive actions are entered and tracked in ECMS.  All compliance and conformance findings are resolved as described in Element 14.

EMS Element 14: Nonconformity, Preventive and Corrective Action

Element Purpose & Overview

MCAS Miramar has defined a structured problem-solving process that allows for the identification and definition of problems with compliance or the EMS, allows for the analysis of root causes and alternative solutions, selects and implements actions, and provides an avenue for follow-up to ensure problems are solved.  Problems are typically identified through compliance audits, monitoring of EMS objectives and targets, and inspection of practices. 

References:
 

Environmental Management Procedure

If problems are discovered throughout the environmental management process, the EMS or unit level defined environmental issues; the Problem-Solving FlowChart  provides direct understanding of the problem and the mitigation avenues to pursue toward resolution.

Any problems that are not readily resolved using this process can have a POA&M developed for tracking, monitoring and measurement.

EMS Element 15: Control of Records

Element Purpose & Overview

MCAS Miramar inventories and maintains records related to its EMS and environmental programs so that those records:

  • Can be located.
  • Are protected from alterations or damage.
  • Are available when and where needed.
  • Are removed from circulation when obsolete and destroyed or archived as appropriate. 
References:
 

Environmental Management Procedure

The EMS Team and EMD Program Managers will identify all record requirements appropriate to environmental programs and practices and essential to the effective operation of the EMS.

The EMS Coordinator will maintain records related to records relating to the monitoring of practices and tracking of objectives and targets, compliance evaluations, EMS audits, and management reviews, using the electronic document library function of EMPortal, and this website.

Environmental program and division managers will maintain records according to regulatory and policy requirements and maintain them at this website, the Miramar internal intranet or local servers, and the USMC’s EMPortal.

Environmental program managers will retain agency records relating to hazardous substance releases per 42 U.S.C 7401-7671, SSIC 5090.3; 33 U.S.C 1251-1387; and 42 U.S.C 300f-300j-26.  (This requirement generally applies to environmental restoration (ER) program records consisting of the ER administrative record for the Miramar.  Other agency records related to the ER program shall, pending promulgation of EPA regulations for their disposition, be retained in accordance with the most stringent requirements of reference 42 U.S.C 7401-7671 and Navy ER program policy.)

All records or classes of records will be noted in the Listing of Environmental Records , which identifies the record owner(s), storage location, storage format (electronic or hard copy), and retention guidelines.

Records are generated and maintained in an electronic format, where possible but, in some cases, hard copy records may be maintained.  In such cases:

  • Hard copy records will be screened for legibility and cases of illegibility will be handled as a nonconformance item.
  • The EMS Coordinator shall review all areas where hard copy records are stored.  Storage of records is provided in secure filing and/or storage cabinets in an environment which prevents damage, deterioration or loss or in an electronic data file with appropriate access control.  Record storage areas shall be secure from unauthorized access and free from reasonable environmental threats (e.g., water leaks, extreme temperatures, etc.).

Record retention requirements are established by various authorities: regulatory agencies, orders, contracts, etc.  Retention times listed on the Listing of Records establish the minimum duration that each type of record must be maintained.  EMS audits will periodically assess record retention requirements.

Records that are maintained beyond applicable retention times will be archived.  Potentially sensitive records, such as personnel-related or legal records, are destroyed prior to their disposal.  Non-sensitive records are managed with other waste office papers.

Training Records

Copies of the previous record and document procedures are contained in the Old Documents Records and Procedures archive document.

EMS Element 16: EMS AUDIT

Element Purpose & Overview

Annually, MCAS Miramar conducts a self-audit of its environmental management system (EMS) to ensure that it is properly implemented and maintained. The annual audit is either a self-audit or is undertaken as part of a benchmark ECE.

References:
 

Environmental Management Procedure

Miramar will conduct an annual self-audit of its EMS, except in those years when a Benchmark ECE is conducted and the Miramar EMS is evaluated as part of the Benchmark.  The self-audit will follow the requirements outlined in MCO 5090.2 (JUN 2018).  These procedures outline the responsibilities and requirements of planning, conducting, recording, and reporting the audits as well as the determination of each audit’s criteria and scope. 

Miramar will report annual EMS self-audit results to HQMC no later than 30 September of each year, via .pdf upload to the EM Portal’s document library and HQMC email notification.  Those reports will be made under appropriate cover signed by the Miramar CO.  Reports will include the following enclosures:

  • Enclosure 1: A summary of the installation’s EMS conformance by element.  
  • Enclosure 2: A copy of the meeting minutes from the installation’s most recent annual Management Review (attended or reviewed by the CO).  MCO 5090.2 paragraph 2217.3 describes for management review documentation requirements.
  • Enclosure 3: A copy of each auditor's EMS Lead Auditor Training certificate with refresher training dates annotated, as applicable.

The subject line of the submittal cover letter shall read, "USMC ANNUAL EMS CONFORMANCE SUMMARY" and shall state whether the installation IS or IS NOT in conformance with Marine Corps standards.

Miramar will self-declare EMS conformance at least every three years; annual conformance reports and external EMS audits every three years as part of the HQMC ECE validation will satisfy this requirement.

Next Page: Management Review - EMS Element 17

Marine Corps Air Station Miramar-EMS