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Comprehensive Compliance
By Nimonik
Tame the compliance beast
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Why?Standards and regulations are (often) born of disaster. Disasters should not happen.
https://www.youtube.com/watch?v=XTopVi1hVVM
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AgendaNon-compliance risks
Compliance challenges
How to achieve comprehensive compliance
Q/A
01
02
03
04
05
Case study - Lac Megantic
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Non-compliance risks
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Non-compliance risks5 risks
Risks of non-compliance
Accidents
Penalties
Reputation damage
Product delays and
market access
Regulated out of
business
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Penalties
https://www.epa.gov/enforcement/enforcement-annual-results-numbers-glance-fiscal-year-2017
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When non-compliance happens
• 2015, Los Angeles, “The Safety Manager was sentenced to three years of probation and will face fines and penalties of about $19,000 after pleading guilty to a single felony count of violating a workplace safety rule that caused a death.” – The Guardian
• 2016, Iowa, a business owner was sentenced to 24 months incarceration. He was also sentenced to three years supervised release following his imprisonment. He is required to pay $789,138.03 in restitution for knowingly storing hazardous waste without a permit. - EPA
• 2017, Ontario, “At least 11 employers sentenced to jail for safety violations in Ontario, figures show” –CBC
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Penalties
Source: EPA 2018 report
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Reputational damage
Source: X. D. Xu et al
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Reputational damage
Source: X. D. Xu et al
CAR - Cumulative Abnormal Return
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Reputational damage
Source: X. D. Xu et al
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Market access/Product delays
• German automotive parts company supplier shutdown in China
• 200 car models and 49 makers affected
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Regulated out of Business
• “186. An inspector may order the suspension of work or the complete or partial shutdown of a workplace and, if necessary, affix seals, if he considers a worker’s health, safety or physical well-being to be endangered.” – Act respecting occupational health and safety, Quebec
• “China Shuts Down Tens Of Thousands Of Factories In Widespread Pollution Crackdown” – Oct. 2017, Forbes.com
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Role of compliance
• From lagging to leading• From reactive to proactive• EHS Strategy
Comprehensive EHS Compliance
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EHS Excellence
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Benefits of compliance
• Motivate workforce to take action• Reduce risk of penalties• Get ahead of new and
changing regulations• Lower risks
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New requirementsISO 14001:2015 and ISO 45001:2018
Source: ISO 14001:2015
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New requirementsISO 14001:2015 and ISO 45001:2018
Source: ISO 14001:2015
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New requirementsISO 14001:2015 and ISO 45001:2018
Source: ISO 14001:2015
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Compliance challenges
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Compliance challenges
• Unsustainable programs
• Reduced workforce
• Increasing demand
• Poor processes
• Sporadic improvement
• Poor resources/knowledge
• Lack of support/attention from other departments
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How to achieve comprehensive compliance
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-compliance
and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Step 1
1. Fully understand
1)The organization 2)Its context3)Its scope4)Risks and opportunities5)Environmental aspects
1. Search, evaluate applicability, and classify
Identify your applicable regulations, codes and standards
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Step 1
• Jurisdictions – International, Federal, Provincial/State, Municipal,… (include key industry and customers’ requirements if necessary)
• Legislation Statuses: Proposed – Published – In Force – Repealed
• Document Type: Acts & Laws, Regulations, Guidance, Standards, Notice, order & directive
• Source:
Identify your applicable regulations, codes and standards
Source: CFR, EPA,OSHA, MINSA websites, consultants
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Step 1
Tool - Excel
Identify your applicable regulations, codes and standards
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Step 1
Tool – Software
Identify your applicable regulations, codes and standards
Source: NimonikApp
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-
compliance and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Step 2Select requirements that apply to you
• Identify each applicable requirement within a legislation
• An example: Regulation of Health & Safety• In total: 338 clauses• No specific department is responsible
for the whole regulation• Specific clauses need to be assigned to
appropriate team/expert
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Step 2
Tool - ExcelSelect requirements that apply to you
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Step 2
Tool - Software
Source: NimonikApp
Select requirements that apply to you
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-compliance
and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Step 3Implement a process with your subject matter experts
• Start with reports and work backwards• Map to organizational structure• Clear accountability
• Compliance is never the sole responsibility of EHS team
• Compliance must be cultural
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Step 3
Tool - Software
Source: NimonikApp
Implement a process with your subject matter experts
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-compliance
and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Step 4Document your compliance actions
• Procedures & Processes:• Compliance management procedures• Compliance required procedures
• Records:• Internal and external communication• Implementation outcome evidence
• Permits & License:• National Pollutant Discharge Elimination
System (NPDES) Permit
Policy
Manual
Procedures
Work instructions/SOPS
Records and forms
Why?
Who when where?
How?
Evidence
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-
compliance and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Step 5Monitor for changes to your requirements
California bills passed in 2018
Periodical review key websites
RSS from official websites
Newsletters from consulting companies
Source: BillTrack50
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-
compliance and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Step 6Verify compliance with audits and management reviews
Audit (Internal & External)
• Preparation (compliance obligations, process, evidence, evaluation outcomes, key CO elements
• Output (finding reports on activity & outcome, )
• Tips: (find the CO for each audit finding)
Compliance Management Evaluation
• When? (Real-time, periodical, internal or external changes)
• What aspects? • your capability (culture,
systems, people) to be in compliance,
• the effectiveness of your compliance programs to reduce risk,
• the advancement of compliance outcomes.*
• How? (Leading indicators and lagging indicators)
Management Review
• Preparation (summary of changes, gaps, proposals, SWOT)
• Output (records of compliance status, action plans, risk assessment, annual EHS OTP (objective, target, planning))
Source: Lean compliance
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Tier 3Challenges to safety systems3
Tier 4Operating discipline & management system
performance indicators4
Tier 1LOPC events of greater consequence
1
Tier 2LOPC events of greater
consequence2
Source: ANSI/API RP 754 [4]
Leading indicators
Lagging indicators
Step 6Verify compliance with audits and management reviews
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-
compliance and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Step 7
• Define Corrective and Preventive Action Plan (CPAP) with responsible expert
• Ensure the documentation of correction process and result
• Effectiveness assessment
Take action on non-compliance and opportunities for improvement
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Step 7
Recommend to use a system to track all the findings:
• No delay - notify higher level supervisor directly
• No miss – status summary of all findings
• Full records –communication, correction result
• Key for due diligence
Take action on non-compliance and opportunities for improvement
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7 steps for comprehensive compliance
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
Plan
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-compliance
and opportunities for improvement
Do
Check
Act
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
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Case studyLac Meg antic
July 6th, 2013
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Lac Megantic overview
• July 6, 2013• US based MMA Railway train carrying
crude oil derailed in Lac Megantic• 47 deaths and 6 million litres oil spill • Penalties of 1M and ongoing lawsuits• 6 ex-MMA employees pled guilty to
violating the Railway Safety Act.
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MMA compliance background
● Poor safety culture at MMA● Always on Transport Canada’s inspection list● Recurring audit findings● Safety management system in writing not in
action● Inadequate corrective actions - eg lead
automotive engine failure repaired with epoxy
Source: Transport Safety Board of Canada
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Events leading to Lac Megantic● Cars with outdated design, carrying highly
explosive oil● The lead locomotive with parts repaired with epoxy
started to fail, but was ignored ● Applies air and hand brakes when rules require only
hand brakes● 7 hand brakes instead of 9● Tests hand brakes with air brakes applied● Leaves the train unattended - no company policy● No company procedure on the smoky engine ● Defective lead locomotive catches fire● Firefighters turn off the locomotive fuel supply● MMA sends a foreman who releases firefighters
and leaves ● With the locomotive off, air brakes fail, hand brakes
are not sufficient, train rolls down, derails and explores, killing 47
Source: Transport Safety Board of Canada
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Step 1Identify your applicable regulations, codes and standards
Poor identification - eg frequent Transport Canada’s audit findings
Step 2 Select requirements that apply to you Did not understand applicable Canadian Rail Operating rules - eg handbrakes
Step 3 Implement a process with your subject matter experts Experts not involved - eg highly explosive materials in outdated cars
Step 4 Document your compliance actions Improper documentation - eg fire dept turned off engine
Step 5 Monitor for changes to your requirements Improper monitoring - eg warnings issued about Class 111 cars
Step 6 Verify compliance with audits and management reviews Poor safety culture and MS as is evident from Transport Canada’s findings
Step 7Take action on non-compliance and opportunities for improvement
Poor safety culture - lead locomotive fixed with epoxy
How MMA failed in the 7 steps of comprehensive compliance
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7 steps and the Swiss Cheese model on how accidents happen
Accident trajectory
Losses
Organizational InfluencesStep 1 and 2
Unsafe SupervisionStep 3,4,5
Preconditions for Unsafe actsStep 6 and 7 Unsafe Acts
Step 3
● Identify your applicable regulations, codes and standards
● Select requirements that apply to you
● Implement a process with your subject matter experts
● Document your compliance actions
● Monitor for changes to your requirements
● Verify compliance with audits and management reviews
● Take action on non-compliance and opportunities for improvement
● Implement a process with your subject management reviews
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Take away
• Compliance is the foundation for EHS management
• Be proactive, not reactive
• Setup a thorough and continuous improving compliance system
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We improve the world by helping companies respect environmental, health, safety & quality requirements.
Established 2008
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Our Services and products
Software
EHS regulatory tracking
Audit protocolsEHS database
NimonikApp Mobile Auditing app
EHS Regulatory Content
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How Nimonik can help in these 7 steps
2Select requirements that apply
to you
3Implement a process with your
subject matter experts
4Document your compliance
actions
5Monitor for changes to your
requirements
7Take action on non-
compliance and opportunities for improvement
1Identify your applicable
regulations, codes and standards
6Verify compliance with audits and
management reviews
ContinuousImprovement
● Mobile Auditing● NimonikApp● Audit protocols
● EHS database
● EHS database ● NimonikApp
● NimonikApp● NimonikApp● EHS regulatory tracking
● Mobile Auditing● NimonikApp
Plan
Do
Check
Act