CHEMICAL
MANUFACTURERS
ASSOCIATION
United States
Environmental Protection
Agency
Office of Enforcement and
Compliance Assurance
(2221 A)
EPA-305-R-99-001
May 1999
EPA/CMA Root Cause
Analysis Pilot Project
An Industry Survey
GOT CAUSE
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DISCLAIMER
The information included in this document is a consolidation of the
EPA/CMA Root Cause Analysis Pilot Project survey responses and
ideas that may help address some environmental issues identified in
the survey responses. This document is intended to assist
environmental managers, regulators, and other interested parties to
better understand the causes of noncompliance and to consider
recommendations and ideas that may help improve environmental
compliance and performance. While the categories of noncompliance
and root causes discussed in this report were developed by the
project team, the characterization of particular noncompliance events
in terms of those categories was based entirely on individual survey
responses. It should be emphasized that EPA has neither reached any
conclusions nor made any decisions in response to the findings,
recommendations, or ideas for compliance assistance; or EPA policy,
regulatory, or statutory changes included in this document. This
document is not a substitute for complying with the regulations
themselves. Neither CMA nor EPA makes any guarantees or
assumes any liability with respect to use of any information,
recommendations, or ideas contained in this document.
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ACKNOWLEDGMENTS
This document is the result of a partnership between the Chemical
Manufacturers Association (CMA) and the Environmental Protection
Agency (EPA). The background, experiences, and creativity of the
following people were essential in developing this document.
CMA
Jamie Conrad
Christina Franz
Industry Representatives
Dan Bennewitz, Olin Corporation
Richard DeSanti, Mobil Chemical Company,
A Division of Mobil Corporation
Jim Doyle, Exxon Chemical Corporation
Ed Mongan, DuPont
George Woehr, Occidental Chemical Corporation
EPA, Office of Enforcement and Compliance Assurance
Tracy Back
Joanne Berman
Reggie Cheatham
Emily Chow
Walter Derieux
John Ellison
John Mason
Charles Perry
Sally Sasnett
Richard Satterfield
EPA, Region I
Gina Snyder
EPA, Region X
Jeff Kenknight
Through a peer-review process, the project team received and
incorporated valuable comments into the report. We appreciate the
time and effort of our peer reviewers.
OTC1
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EXECUTIVE SUMMARY
Purpose
The U.S. Environmental Protection Agency (EPA) and the regulated
community continually seek effective and efficient methods of
improving compliance with environmental regulations. From 1996
through 1998, EPA and the Chemical Manufacturers Association
(CMA) worked together to pilot an approach for identifying and
evaluating the root causes (that is, underlying causes) of
noncompliance with regulatory requirements, to identify
recommendations for improving compliance, and to provide insight
into the effect of environmental management systems (EMS) on
compliance. To obtain information from certain CMA member
facilities, the project team developed a survey focused on the following
four questions:
• What are the root causes of noncompliance?
• How do facilities respond to noncompliance events and what are
the lessons learned?
• How have Responsible Care® and other management systems
affected the overall environmental performance of facilities?
• What changes on the part of the facility or the Agency will improve
compliance and the efficiency of the compliance process?
This report summarizes survey responses to questions regarding the
root and contributing causes of noncompliance and makes
recommendations, for industry and government, to improve
compliance with environmental regulations. The report should be of
value to the regulated community, state and federal regulators, and
other persons interested in the challenge of promoting regulatory
compliance.
A thorough examination of the causes of noncompliance is a valuable
tool that can help improve compliance and minimize the occurrence of
noncompliance. Any root cause analysis should focus on an
exhaustive and diligent identification of all causes and the
implementation of corrective measures that may yield long-term
solutions.
Because of the limitations of the data on which this report is based
(addressed in more detail on page 5) the results of this survey are
representative only of large CMA member facilities in the project's study
population. Beyond this study population, the project findings should
be considered largely as a guide to further root cause research.
Types of Noncompliance
The four types of noncompliances identified most frequently by
survey respondents, in order, are:
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• Report Submissions and Reporting: Failure to submit required
reports or the submittal of incomplete or inaccurate reports to
the regulating agency
• Exceedance: Failure to meet discharge limit(s), as defined in the
facility's permit or by regulation
• Operations and Maintenance: Noncompliance of an operations
and maintenance nature
• Record Keeping: Failure to maintain operating records or files
in accordance with regulations
Root Causes
Multiple causes were identified for 94 percent of the noncompliance
events identified.
The six categories of root causes and the specific causes within each
category identified most frequently, in order, are:
• Regulations and Permits - facility unaware of applicability of a
regulation
• Human Error - individual responsibility or professional judgment
• Procedures - operating procedure not followed
• Equipment Problems - design or installation
• External Circumstances - contracted services, such as haulers or
handlers
• Communications Difficulties - between facility and regulatory
agencies
Contributing Causes
The four categories of contributing causes and the specific causes
within each category identified most frequently, in order, are:
• Management - environmental aspects of facility process and
operations not identified
• Procedures - reporting or notification procedures unclear
• Regulations and Permits - contradictory interpretation of state or
federal regulations
• Compliance Monitoring - audit program insufficient and routine
site and equipment checks not conducted
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Responsible Care® and Other Environmental Management Systems
Survey responses indicate that there is a strong relationship between the
implementation of Responsible Care® or other EMSs and compliance.
However, even a complete, well documented EMS does not, by itself,
ensure 100 percent compliance with environmental requirements.
Survey responses also indicate that facilities are modifying or clarifying
their EMSs to minimize the incidence of noncompliance events:
• The majority of responses identified environmental audit
programs; corporate policies, goals, targets, and guidelines; and
Responsible Care® as management methods that have a strong
influence on environmental performance.
• Among the respondents, 78 percent had modified their EMSs in
response to a noncompliance event.
• Among the respondents, 41 percent stated that Responsible Care®
or another EMS would have contributed to prevention of the
noncompliance event.
• The project team considers 71 percent of the actions taken in
response to a noncompliance event relevant to an EMS.
Respondents' Perspectives on Improving Compliance
Respondents' perspectives on traditional and innovative approaches
to improving compliance include:
• Respondents identified increased employee involvement,
improvement of the facility's management system, more clearly
defined commitment on the part of management, and improved
understanding of regulations as the most effective actions industry
could take to improve compliance.
• Respondents identified tools developed by the facility, facility
employees and corporate staff, and trade associations as the most
useful sources of compliance assistance, indicating the industry's
historical reliance on in-house support.
• Respondents recommended that government work with industry
to provide more technical assistance, including guidance,
documents, self-audit check lists, logic or applicability flowcharts,
and workshops—ideally for each new rule.
• Respondents recommended a range of policy and regulatory changes,
including the development of "plain language" rules, pilot testing of
new rules, consolidation of overlapping regulatory requirements, and
reduction of record keeping and reporting requirements.
• Respondents suggested that self-audits, third-party audits, EMS audits,
or other forms of self-monitoring, potentially coupled with penalty
relief, be used as alternatives to traditional compliance inspections.
• Respondents suggested that EPA reduce the frequency of compliance
inspections for facilities that have good compliance records.
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Recommendations
Industry should consider the following actions to improve compliance:
• Ensure that all EMS elements are in place and all employees
understand that the elements are part of the facility's EMS.
• Implement a program that promotes high levels of awareness of
and commitment to the EMS among employees at all levels.
• Increase awareness among management and employees of the
central role that a comprehensive EMS can play in achieving and
maintaining compliance.
• Focus efforts on identifying more opportunities for rigorous
implementation and evaluation of EMSs.
• Establish accurate, standard operating procedures that all
affected employees can understand.
• Train employees to ensure that new and modified operating
procedures are implemented properly.
EPA should consider the following actions to promote compliance
with regulations:
• Articulate new regulations more clearly.
• Work with state agencies to ensure that regulations are
interpreted consistently.
• Continue compliance assistance and outreach activities.
• Consider the development of compliance assistance tools, such as
plain-English guides for every new rule.
• Provide more incentives for industry to disclose violations.
Individually, and working together, EPA and various industry sectors
should pursue additional root cause analyses of noncompliance to
better understand the findings and recommendations discussed in
this report. Such analyses might focus on:
• Understanding why and in what situations violations occur at
facilities with EMSs.
• Looking more carefully at the "human error" category of causes
used in this report.
• Involving, at the design stage of the analysis, a statistician and
social psychologist.
• Studying noncompliance at small (less than 100 employees)
companies.
• Conducting more research through discussions between EPA
and industry to more fully understand the relationship between
particular violations and appropriate corrective actions.
T"
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TABLE OF CONTENTS
1. INTRODUCTION 2
Creating the Partnership 3
What is the Chemical Manufacturers Association? 3
Why the Partnership? 3
Project Development 4
Criteria for Selecting Recipients of the Survey 5
Application and Limitations of the Survey Responses 5
Structure of the Survey 5
Demographics of Responding Facilities 7
Applicability of Environmental Statutes 9
2. NONCOMPLIANCE AND ROOT CAUSES 10
Chapter Highlights 10
Discussion 11
Noncompliance Events 13
Root and Contributing Causes 22
3. ENVIRONMENTAL MANAGEMENT SYSTEMS AND COMPLIANCE ... 26
Chapter Highlights 26
Discussion 27
Background 27
EMS Findings 28
Implementation Status 29
Changes in Response to Noncompliance 31
Effect on Compliance 31
4. RESPONDENTS' PERSPECTIVES ON IMPROVING COMPLIANCE .... 34
Chapter Highlights 34
Discussion 35
Recommendations and Ideas for Compliance Assistance and Regulatory Change 35
Other Compliance and Enforcement Perspectives 37
5. RECOMMENDATIONS 42
Chapter Highlights 42
Discussion 43
Strengthen Awareness and Implementation of EMSs 43
Streamline Regulations and Create Compliance Assistance Tools 47
Statute-Specific Recommendations 48
Promote and Improve Self-Audit Incentives for Sustained Compliance 51
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APPENDIX A - RESPONSES TO SURVEY QUESTIONS AND
DATA LIMITATIONS
APPENDIX B - DEFINITIONS OF NONCOMPLIANCE CATEGORIES
APPENDIX C - ROOT AND CONTRIBUTING CAUSE CATEGORIES
AND SPECIFIC CAUSES
APPENDIX D - STATUTES
APPENDIX E - COMPARISON OF THREE EMS MODELS
APPENDIX F - RESPONDENT RECOMMENDATIONS RELATED
TO SPECIFIC STATUTES
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EPA/CMA ROOT CAUSE
ANALYSIS PILOT PROJECT
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_ Chapter 1
INTRODUCTION
The U.S. Environmental Protection Agency (EPA) and industry share a
vital interest in exploring new approaches for improving compliance
with environmental laws, reducing risk of environmental harm, and
raising awareness of environmental issues. One way to help improve
compliance and environmental performance is to understand why
there is difficulty complying with environmental laws—a question to
which the answer is not obvious. In short, regulators and industry
need to conduct root cause analyses. The goal of this root cause
analysis project is to improve environmental performance by
understanding (1) the causes of noncompliance and (2) the impact of
environmental management systems (EMS) and the Chemical
Manufacturers Association's (CMA) Responsible Care® initiative on
compliance.
This report presents an overview of survey responses from industry
representatives about the root and contributing causes of
noncompliance events that were identified in federal civil judicial or
administrative actions. It also offers suggestions for improving
compliance by minimizing the occurrence of those causes. As a
follow-up activity, input from EPA personnel involved with these
federal judicial or administrative actions will be sought to obtain their
perspective on the causes of the noncompliance events.
Any industry sector can use the findings and recommendations in
this report in a variety of ways, depending on a facility's size and level
of sophistication. For example, many suggestions in this report
include activities related to EMSs. Facilities presently implementing
an EMS can use the findings in this report to either reinforce the value
of their existing EMS or to encourage further evaluation of the EMS.
Facilities that do not have EMS experience can use the report as a
guide regarding important EMS elements and implementation
considerations. The information in this report can also be used by
federal and state regulators to improve new and existing rules and to
optimize their compliance assistance efforts. Working together,
industry and regulators can use the findings of this project to fulfill
environmental goals and objectives through a better understanding
of the issues associated with regulatory compliance. Specifically, the
findings and recommendations in this report may encourage
industry and regulatory agencies to consider the following activities:
• Conduct additional root cause analyses
• Use future root cause analysis results to validate and refine the
results of this report
• Modify environmental policy to incorporate changes based on the
findings of root cause analyses
• Encourage the support of management to bring about behavioral
changes among employees that will promote compliance
• Implement the recommendations discussed in Chapter 5 of this
report
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Creating the Partnership
EPA's Office of Enforcement and Compliance Assurance (OECA),
CMA, and an ad hoc committee of CMA member companies created
a partnership to achieve the project goals. The partnership between
EPA and CMA represents the first time EPA and representatives of
the regulated community have worked together to develop an
understanding of the root causes of noncompliance and analyze
recommendations for improving environmental performance. The
partnership was documented in a Memorandum of Understanding
that identified the terms and conditions of the partnership and
established the project's framework. The parties called the effort the
EPA/CMA Root Cause Analysis Pilot Project.
What is the Chemical Manufacturers Association?
CMA represents chemical manufacturers that have operations in the
United States and internationally. Founded in 1872, CMA is one of
the oldest manufacturing trade associations in the Western
Hemisphere. CMA's member companies account for more than 90
percent of the productive capacity for basic industrial chemicals in
the United States. Manufacturers of chemicals and allied products
provide more than one million jobs for American workers and are the
nation's leading exporters, with total exports in 1997 of $69.4 billion.
CMA brings together member company experts to help resolve
industry wide policy, technical, and scientific problems. CMA
communicates and works with government and the public on vital
issues and administers research, studies, and tests on a wide range of
chemical products and practices.
Why the Partnership?
To understand why noncompliance occurs and how facilities respond
to noncompliance events, EPA recognized the need to work with
industry. CMA represents a sophisticated industry that conducts
a number of manufacturing processes that make the industry
subject to most federal environmental statutes. The broad
applicability of environmental regulations to the chemical industry
provided the opportunity to identify and assess the causes of
noncompliance with a wide range of regulatory programs.
Working with CMA provided EPA the opportunity to understand
the chemical industry's perspective on the causes of noncompliance
with those statutes and the industry's recommendations for
improving its environmental performance.
CMA participated in the project because it offered a unique
opportunity to work jointly with EPA to discover the root causes of
certain noncompliance events. CMA actively seeks partnerships
with government to try to resolve the important environmental and
compliance issues that confront both industry and government.
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CMA was particularly intrigued by EPA's interest in the views of
facility personnel about how and why past noncompliance events
occurred and about ways in which compliance and regulations can
be improved. That unique aspect of EPA's proposed project
represented a departure from the less interactive approaches taken
under similar government-sponsored projects.
The information gathered and the lessons learned in this project
provide EPA, CMA, and other industry groups new opportunities to
improve environmental compliance. EPA will be better able to further
its regulatory reinvention and compliance assistance activities, and
industry can incorporate the recommendations into daily operations
to effect behavioral change. EPA and industry also can create
environmental policy that better serves the needs of industry,
government, and the public. EPA and CMA believe that these
opportunities can be duplicated in future collaborative efforts, such as
additional root cause analyses, to improve compliance and
environmental performance.
Project Development
The project team developed a survey to gather information from
facility personnel that respondents could complete with minimal
burden. Once responses were received, EPA and CMA worked
jointly to analyze them. Important project events are highlighted in
the box below.
The Project Process
• Agreement on project goals and scope, August 1 996
• Negotiation of a Memorandum of Understanding between EPA and CMA, December 1 996
• Formulation of target questions and development of survey, January 1 997
• Identification of candidates to receive the survey, January to March 1 997
• Submittal of an information collection request (ICR) to the U.S. Office of Management and Budget
(OMB) (ICR No. 1 792.01, OMB Control No. 2020-0008), April 1 997 and two Federal
Register (F.R.) notices in compliance with the Paperwork Reduction Act, 44 U.S.C. § 3501 et
seq. (61 F.R. 41 605-41 606 and 62 F.R. 27599-27600)
• Distribution of survey, October 1 997
• Collection of responses, concluded in March 1 998
• Review of responses, January to June 1 998
• Assessment of representativeness of responses, October 1 998
• Production of draft report, June 1 998 to Decemberl 998
• Conduct peer review, January 1 999 to March 1 999
• Issuance of final report, May 1 999
To preserve the anonymity of respondents, CMA distributed the survey and collected the responses.
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Criteria for Selecting Recipients of the Survey
Survey recipients were CMA member facilities that had been parties
to a federal civil judicial or administrative action that commenced and
concluded between 1990 and 1995. Applying this criteria, 50 facilities
that had been involved in 79 enforcement actions were identified. Of
those facilities, 27 facilities involved in 47 enforcement actions
voluntarily completed and returned the survey.
Application and Limitations of the Survey Responses
Fifty CMA facilities met the criteria established for the pilot project.
Because these facilities were not randomly chosen, the findings of this
project do not have broader application to larger populations with
statistical validity. However, survey responses received from large
(more than 100 employees) CMA member facilities within Standard
Industrial Classification (SIC) code 2869 (Industrial Organic Chemicals,
Not Elsewhere Classified) were sufficiently numerous to adequately
represent all large CMA facilities in the study population. Additional
limitations of the data set are discussed in Appendix A. More
generally, the results of the survey can be viewed as an initial guide
to some frequent causes of noncompliance, as identified by 27
facilities that were party to a total of 47 federal enforcement actions.
These findings also can serve as an excellent guide for conducting
additional root cause work to validate and refine the findings of this
survey of root causes of noncompliance.
Structure of the Survey
To obtain information from certain CMA member facilities, the
project team developed a survey focused on the following four theme
questions:
• What are the root causes of noncompliance?
• How do facilities respond to noncompliance events, and what
are the lessons learned?
• How have Responsible Care® and other management systems
affected the overall environmental performance of facilities?
• What changes on the part of the facility or the Agency will improve
compliance and the efficiency of the compliance process?
Generally, respondents were asked to:
• Categorize noncompliance events described in federal complaints
or settlement documents
• Identify root and contributing causes of the noncompliance events
• Identify any actions taken in response to noncompliance events
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• Identify how the facility verified that actions taken would
promote compliance
• Describe any lessons learned from the noncompliance events and
actions taken
• Describe the facility's EMS at the time of the noncompliance events
and any changes made to the EMS since the noncompliance event
to prevent its recurrence
• Provide their views about ways to improve compliance with
regulatory requirements and identify compliance assistance tools
and activities they need
• Provide their views about traditional and innovative compliance
and enforcement activities
Appendix A presents the questions asked in the survey and quantifies
the number of responses to each question. Appendix A also discusses
the limitations of the survey.
Respondents characterized violation(s) identified in the complaint(s)
or settlement document(s) as noncompliance event(s), according to
15 categories provided and the statute under which the
noncompliance event occurred. The 15 noncompliance categories
defined in the survey are listed below. Appendix B presents
definitions of these categories.
Noncompliance Categories
• Corrective Action Activities "Record Keeping
• Equipment/Unit DesiSn . Report Submissions and ReportinS
• Exceedance . c -n /D i
• opills/Keleases
• Failure to Respond
• Labeling
• LeSal ASreement * Trainins/Certification
• Monitoring/Dectection/Control • Unpermitted/Unauthorized Activity
• Operations and Maintenance • Waste Identification
Survey respondents were provided the following definitions of root
and contributing causes.
• Root cause: A primary factor that led to the noncompliance
event
• Contributing cause: A secondary factor that led to the
noncompliance event
The survey identified 12 general categories of causes. Each general
category was then subdivided into specific causes, a total of 74. An
"other" category also was provided for cases in which the predefined
categories did not describe the root or contributing cause(s) of a
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WWW Site
A copy of the EPA/CMA Root Cause Analysis
Pilot Project Survey is available at the following
Internet address:
noncompliance event adequately. Appendix C lists general
categories of causes and specific causes identified in the survey.
Respondents were asked to select no more than three root causes from
among the 74 specific causes and to select any number of contributing
causes to characterize the noncompliance event. To facilitate
completion of the survey, respondents were directed to address
similar noncompliance events as a single event. For example, if a
facility had a number of noncompliance events related to reporting
requirements under the Clean Air Act (CAA), all such events were
identified as a single noncompliance event. Throughout this
document, the general categories of causes and specific causes are
printed in bold italic type and italic type, respectively.
Demographics of Responding Facilities
The survey requested basic demographic information, including:
• Primary SIC code of the facility
• Number of employees located at the facility at the time of the
noncompliance event (full-time employees and contractors)
Example Category
of Cause and
Associated Specific
Causes
Category:
Human Error
Causes:
1. Individual
responsibility or
professional judgment
2. Fatigue, lack of
alertness, distraction
3. Inexperience, lack of
knowledge, lack of
technical expertise
4.Other (specify)
• Description of the activities currently
conducted at the facility
• Number of years the facility has been
in operation
• Job responsibilities of the person(s)
completing the survey1
The demographic information provides
background information about the
facilities at the time of the noncompliance
event, as well as at the time the survey was
completed.
Profile of Typical
Participating Facility
Primary SIC code 2869, Industrial Organic
Chemicals, Not Elsewhere Classified
More than 1 00 full-time employees
Conduct of chemical production activities
In operation for more than 10 years
1 In 13 responses, more than one person was identified as having helped
to complete the survey.
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Of the 27 facilities that responded to the survey, almost half (48%)
identified their primary SIC code as 2869. The figure below presents
the SIC codes identified by the respondents.
Primary SIC Code of Facilities
A majority of respondents
(81%) stated that their
facilities employed more
than 101 full-time
employees and 0 to more
than 500 full-time
contractors at the time of
the noncompliance event.
A majority of survey
respondents (81%) stated
that chemical production
activities currently are
conducted at the facility.
All the respondents
indicated that their facilities
had been operating for
more than 10 years.
Facilities located in EPA
regions 2, 3, 5, 6, and 9
responded to the survey,
as the map below shows.
The job responsibilities most commonly reported by the individuals
completing the survey were compliance staff and environmental
engineer, as the figure on the next page shows.
2812-Alkalies and Chlorine
2819 - Industrial Inorganic Chemicals,
Not Elsewhere Classified
2821 - Plastics Materials, Synthetic Resins,
and Nonvulcanizable Elastomers
2833 - Medicinal Chemicals and Botanical
Products
2843 - Surface Active Agents, Finishing Agents,
Sulfonated Oils, and Cleaning Preparations
2861 - Gum and Wood Chemicals
2869 - Industrial Organic Chemicals,
Not Elsewhere Classified
2879 - Pesticides and Agricultural Chemicals,
Not Elsewhere Classified
2911 - Petroleum Refining
5169 - Chemicals and Allied Products, Not
Elsewhere Classified
4 6 8 10
Number of Facilities
12
14
Regional Distribution of Facilities
Responding to Survey
Region 2 - 9 Facilities
Region 3 - 1 Facility
Region 5 - 2 Facilities
Region 6-14 Facilities
Region 9 - 1 Facility
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Job Descriptions of Respondents
Environmental
Supervisor 2%
Attorney 4%
Site Environmental
Coordinator 4%
Compliance
Staff 34%
Corporate
Manager 9%
Plant Manager 1 7%
Environmental
Engineer 30%
Applicability of Environmental Statutes
Responses to the survey associated noncompliance events with six federal
environmental statutes. Appendix D presents a more detailed discussion
of the responses, organized according to statute. The figure below
illustrates the distribution of noncompliance events under the various
environmental statutes identified by respondents. Because the study only
covered federal enforcement actions, the data may disproportionally
identify noncompliances under statutes for which EPA, rather than states,
has primary enforcement authority. The relative ranking of noncompliance
events by environmental statute is similar to the relative ranking of
violations by environmental statute identified in a study of the entire SIC
major group 28 (Chemicals and Allied Products) universe for the time
period 1990 to 1994. Both studies identified RCRA, the CWA, and the CAA
as the statutes under which the largest numbers of noncompliance events
or violations occurred. The Chemical Industry National Environmental
Baseline Report 1990-1994 (EPA 305-R-96-002) provides more information on
the SIC code 28 universe and the compliance history of those facilities.
Noncompliance Events Under Environmental Statutes
TSCA12%
CAA
20%
Environmental Statutes
Identified in Surveys*
• Clean Air Act (CAA)
• Comprehensive
Environmental Response,
Compensation, and
Liability Act (CERCLA)
• Clean Water Act
(CWA)
• Emergency Planning and
Community Right-To-
Know Act (EPCRA)
• Resource Conservation
and Recovery Act
(RCRA)
• Toxic Substances
Control Act (TSCA)
No noncompliance
events related to the
Federal Insecticide,
Fungicide, and
Rodenticide Act
(FIFRA) were identified
by respondents.
1
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NONCOMPLIANCE AND ROOT CAUSES
Chapter Highlights
The four categories of noncompliance identified most frequently are:
• Report Submissions and Reporting
• Exceedance
• Operations and Maintenance
• Record Keeping
The six categories of causes and specific causes in each category
identified most frequently as root causes are:
• Regulations and Permits - Facility unaware of applicability of a
regulation
• Human Error - Individual responsibility or professional judgment
• Procedures - Operating procedure not followed
• Equipment Problems - Design or installation
• External Circumstances - Contracted services, such as haulers or
handlers
• Communications Difficulties - Between facility and regulatory
agencies
The four categories of causes identified most frequently as
contributing causes are:
• Management
• Procedures
• Regulations and Permits
• Compliance Monitoring
10
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Discussion
This chapter presents the survey findings about noncompliance events
and their root causes. The first section organizes the findings according
to the four most frequently reported categories of noncompliance:
• Report Submissions and Reporting
• Exceedance
• Operations and Maintenance
• Record Keeping
The second section organizes the findings according to the six root
cause categories of noncompliance events identified most frequently:
• Regulations and Permits
• Human Error
• Procedures
• Equipment Problems
• External Circumstances
• Communications Difficulties
Two frequently identified contributing causes of noncompliance
events that were not identified frequently as root causes—
management and compliance monitoring—also are discussed.
Respondents were asked to describe noncompliance events by categorizing
each finding of noncompliance addressed in the complaint(s) or settlement
document(s).2 The 27 respondents identified a total of 69 noncompliance
events. For the 15 categories provided, the figure below depicts the
distribution of noncompliance categories reported by respondents.
Distribution of Noncompliance Categories
Monitoring/Detection/ Control - 6%
Labeling - 3%
Failure to Respond - 4%
Equipment/Unit Design - 3%
Corrective Action Activities - 1 %
Report Submissions and
Reporting29% -
Spills/ Relelases - 6%
/ Testing - 6%
Unpermitted/ Unauthorized
Activity - 6%
Waste Identification 6%
Record Keeping 10%
Operations and
Maintenance"! 0%
Exceedancel 0%
1 Two noncompliance categories, Legal Agreement and Training/Certification, were not identified by respondents.
11
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Respondents also described the actions taken by the facility in
response to noncompliance events. The actions identified by the
respondents were classified in one of seven categories.
Categories of Actions Taken in Response to a Noncompliance Event
Category
Policies and
Procedures
Equipment
Training
Compliance Monitoring
and Auditing
Regulations and Permits
Management
Communication
Any addition to or clarification or modification of -
The philosophy of and overall approach to environmental management and
daily operations
Any machine, machine part, or other device used in a facility's process
Education programs for personnel (full-time employees and contractors)
related to environmental awareness, requirements, and procedures
Tracking and oversight of a facility's operations
A regulation or permit requirement
Supervisor's and planner's approach to ensuring that staffing of the facility
is appropriate and that daily operations proceed smoothly
Strategies for communication among facility managers, employees,
contractors, and regulators
The following figure illustrates the actions taken in response to
noncompliance events in the four categories identified most
frequently. Generally, facilities initiated a number of actions to
address a single noncompliance event. Most actions taken were
managerial or administrative in nature—pertaining to policy,
Type of Action
Equipment: Design,
Operation and
Maintenance
Communications
Actions Taken in Response to Noncompliance
Noncompli,nce C.tegories
Exceedance
Operations and Maintenance
Record Keeping
Report Submissions and Reporting
15 20 25
Number of Actions
12
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procedures, reporting, or training. Actions characterized as policies
and procedures were initiated most frequently (44% of actions) in
response to noncompliance events. Actions characterized as policies
and procedures were initiated in response to noncompliance events
related to all statutes identified by respondents.
Noncompliance Events
The four noncompliance categories identified most frequently, as well
as the categories of causes, specific root causes, and specific
contributing causes associated with them, are illustrated throughout
this section by graphics similar to the one below. Generally, facilities
identified a number of causes for a single noncompliance event.
Noncompliance
Category
ting cause categories and spec/|/<| causes
Jill
13
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Report Submissions and Reporting
The noncompliance category respondents identified most frequently
was report submissions and reporting. Noncompliance events
related to reporting occurred at 56 percent of responding facilities.
The relative frequency of reporting noncompliance events may be
attributable to the inclusion of reporting requirements in all
environmental statutes. Reporting is an integral component of the
environmental regulations and enables EPA and the states to monitor
facilities' compliance with those regulations. EPA also believes
reporting requirements permit the regulating agency to evaluate the
level of protection provided to human health, welfare and the
environment. Some statutes or portions of statutes, such as EPCRA
and CERCLA section 302, consist almost exclusively of reporting
requirements.
Respondents identified noncompliance events related to reporting for
all statutes; however, 65 percent of such noncompliance events were
related to reporting requirements under CERCLA, the CWA, or
EPCRA.
Respondents associated nine root causes with noncompliance events
related to reporting; as the figure to the right illustrates. The root
cause categories identified most frequently for noncompliance events
related to reporting were regulations and permits (27%) and human
error (35%). The specific causes associated with those root causes
included:
• Human error: Individual responsibility or professional judgment
and inexperience, lack of knowledge, lack of technical expertise
• Regulations and permits: Facility unaware of applicability of a
regulation, ambiguous federal regulations, and inconsistent or
contradictory interpretation of federal regulations
The majority of facilities responding (81%) indicated that at least one
action had been taken in response to the event. More than one-third
(38%) changed their internal processes or procedures to prevent the
recurrence of similar noncompliance events.
14
-------
Submissions
and Reporting
expertise
Ability or • ambiguous ^deregulations • Policy - policy not followed
'er>t • inconsistertt^pr conlradict^ry * Procedures - optertfting procedure not followed
interpretation of federal
regulations '<
facility unaware of Applicability
of technical
of a regulation
and operating procedure unclear or out of date
Training - emplo^eej not trained
Communicationsl- difficulties between
employees and difficulties between facility and
regulatory agencies
Process Upset or Failure - over pressure and
controlled releases to a control device (flare)
Compliance Monitoring - audit program
insufficient >•"
External Circumstances - contracted services
such as haulers or handlers
Contributing Causes
• Human error - individual responsibility or professional judgment/ fatigue, lack of alertness, distract n,- and experience, lack of
knowledge, lack of technical expertise
' Procedures - record keeping procedures inadequate and reporting or notification procedures uncle •
' Management - staffing — inappropriate level or expertise, environmental aspects of facility proces and op^ations not identified/
oversight not provided,- and control and oversight of purchased materials, equipment, and servif s not provided or inadequate
' Communications - difficulties between employees and difficulties between facility and regule jry agencies
' Emergency preparedness - emergency preparedness plan insufficient and emergency preparedness plan implementation issues
' Compliance Monitoring - audit program insufficient and no system to ensure timely submission of environmental reports to
regulatory agency
' Regulations and permits - ambiguous federal regulations/ contradiction between state and federal regulations/ inconsistent or
contradictory interpretation of federal regulations/ contradictory interpretation by federal agency/ ineffective reporting structure/
and Q&A on new regulation not sufficient
' External circumstances - contracted services such as haulers or handlers and external phenomenon (for example, weather, theft,
flood, fire)
' Equipment problems - ordinary wear-and-tear
15
-------
Exceedance
Every noncompliance event respondents identified as an
exceedance involved discharge limits under the CWA.
Exceedances occurred at 26 percent of the responding facilities.
Respondents associated seven root causes with exceedance noncompliance
events; as the figure to the right illustrates. The root cause categories
identified most frequently for exceedance noncompliance events were
equipment problems (41%) and procedures (17%). The specific causes
associated with those root causes include:
• Equipment problems: Equipment design or installation, equipment
maintenance, ordinary wear-and-tear, and transfer hoses
• Procedures: No written operating procedures available and unclear or
out-of-date procedures
Management was a significant contributing cause to exceedance
noncompliance events. When management was identified as a contributing
cause, specific causes identified were environmental aspects of facility
process, and operations not identified, and environmental planning or
budgeting not completed.
All respondents said that they took actions in response to the
exceedances. A majority (86%) of the facilities added or modified
equipment to prevent the recurrence of similar noncompliance events.
Many facilities (71%) changed internal procedures, operation manuals,
or reporting activities, while 57 percent trained or retrained employees.
16
-------
£xceedance
• operatinff\procedu(e unclear • Human error -Ju^kperience, lack of
knowledge, lacfy of technical expertise
• Management - environmental aspects
of facility procesf ^nd operations not
identified
or out of oate -.''
'no written operating
procedures available,,
11
I
i i
1' • Process Upset p| Failure - startup of
new wastewater treatment facility
* Regulations and IPermits - calculational
error by agencyff permit resulted in limit
set too low
* External Circumstances - contracted
services such as haulers or handlers
Contributing Causes
• Human error - fatigue, lack of alertness, distraction and spills, specific cause not known
• Policies - environmental objectives and targets unclear and pollution control technologies or 'her tec nical equipment
needs not assessed
• Procedures - operating procedure not followed, no written operating procedures availabl/ and definitions of roles and
responsibilities unclear
• Management - no formal management structure to address noncompliance and follow trough, environmental aspects of
facility process and operations not identified, and environmental planning or budgeting not completed
• Training - training materials unclear or outdated
• Compliance monitoring - audit follow-up procedures insufficient
• Regulations and permits - ambiguous state regulations, contradiction between state and federal regulations, inconsistent
or contradictory interpretation of federal regulations, and permit parameter not measurable in real time
Equipment problems - design or installation and equipment maintenance
T
^
17
-------
Operations and Maintenance
Noncompliance events related to operations and maintenance
(O&M) were identified at 22 percent of the facilities responding. Such
noncompliance events were identified most frequently under the
CAA (57%). Because the CAA regulations establish a number of
detailed operating procedures for end-of-pipe controls, as well as
work practice standards, the frequency with which O&M
noncompliance events under the CAA were identified is not
surprising.
Respondents associated five root causes with O&M noncompliance
events; as the figure to the right illustrates. The root cause categories
identified most frequently for O&M noncompliance events were
procedures (36%), human error (27%), and regulations and permits
(18%). The specific causes associated with those root causes include:
• Procedures: Operating procedure not followed and unavailability
of written procedures
• Human error: Individual responsibility or professional judgment
• Regulations and permits: Facility unaware of the applicability of
a regulation
The two primary contributing causes were compliance monitoring
and management. When compliance monitoring was identified as a
contributing cause, lack of or insufficient compliance checks or audits
was identified as a specific cause. When management was identified
as a contributing cause, environmental aspects of facility process, and
operations not identified, and staffing level or expertise inappropriate
were identified as specific causes.
All but one respondent indicated that actions had been taken in
response to an O&M noncompliance event. The actions taken varied
but included, in order of frequency:
• Modification or development of procedures
• Redesign, replacement, or maintenance of equipment
• Addition of auditing procedures to check open-ended lines
for plugs
• Provision of incentives for consistent compliance
-------
Operations
Maintenance
' operating procedure
not followed
'no written procedures
available
' individual respor
-------
Record Keeping
Noncompliance events related to record keeping occurred at 19
percent of facilities responding. These noncompliance events were
identified most frequently under the CAA (43%), but also occurred
under the CWA, RCRA, and TSCA. Noncompliance events under the
CAA involved National Emissions Standards for Hazardous Air
Pollutants (NESHAP) regulations. Noncompliance events under the
CWA involved requirements governing the preparation of spill
prevention control and countermeasures (SPCC) plans. Record
keeping is an integral component of environmental regulations that
enables EPA and the states to monitor facilities' compliance with those
regulations. EPA also believes record keeping requirements permit
the agency to evaluate the level of protection provided to human
health, welfare and the environment.
Respondents identified four root cause categories associated with
record keeping requirements: human error, regulations and permits,
procedures, and communications difficulties, as the figure to the right
illustrates. The root cause categories identified most frequently for
record keeping noncompliance events were regulations and permits
(38%) and human error (38%). The specific causes associated with
those root causes include:
• Regulations and permits: Facility unaware of the applicability
of a regulation and inconsistent or contradictory interpretation
of federal regulations
• Human error: Inexperience or lack of knowledge
When regulations and permits was identified as a root cause of
noncompliance events related to record keeping, communications
difficulties between facility and regulatory agencies also was identified
as a root cause.
Contributing causes associated with record keeping noncompliance
events include lack of employee training, unclear definitions of roles and
responsibilities, unavailable written procedures, inappropriate level of
expertise, and unidentified environmental aspects of the facility process.
All but one respondent indicated that actions had been taken in
response to noncompliance events related to record keeping. Most of
the actions taken involved development or revision of procedures
(71%). Other actions involved the training or retraining of employees
(29%).
20
-------
Record Keeping
1 individual responsibility or
1 facility unaware of applicability • Procktiures - record keeping
professional juagjnent of a regulation
' inexperience,! lack of knowledge, 'inconsistent or contradictory
lack of techni§a{ expertise interpretation of federal
regulations
procedures inadequate
I
Communications - difficulties
between facility and regulatory
agencies
Contributing Causes
• Human error - inexperience, lack of knowledge, lack of technical expertise
• Procedures - no written operating procedures available, definition of roles and responsibilities unclear, and reporting or
notification procedures unclear
* Management - staffing—inappropriate level or expertise and environmental aspects of facility process and operations
not identified
* Training - employee not trained
' Regulations and permits - ambiguous federal regulations, contradiction between state and federal regulations,
inconsistent or contradictory interpretation of state regulations, and rule implementation time frames are too short
T
.
21
-------
Root and Contributing Causes
This discussion examines the six root causes of noncompliance
events respondents identified most frequently. Root causes are
discussed in the order of the frequency with which they were
identified, from most to least often.
• Regulations and Permits
• Human Error
• Procedures
• Equipment Problems
• External Circumstances
• Communications Difficulties
Two contributing cause categories that were not identified
frequently as root causes—management and compliance
monitoring—also are discussed. The table below provides an
overview of the categories and the number of times respondents
identified them.
Root and Contributins Causes
Cause Categories
Regulations and Permits
Procedures
Equipment Problems
External Circumstances
Process Upset or Failure
Training
Policies
Management
Other
Compliance Monitoring
Emergency Preparedness
'
^^
=3
E=i
— i
H
i
i
i
i
i
i
• Root C
• Contrlb
|
ause
utlns Cause
0 5 10 15 20 25 30
Number of Times Identified as a Root/Contributing Cause
Regulations and Permits
The root cause categories identified most frequently for
noncompliance events were regulations and permits and human
error. Regulations and permits also was the third most frequently
identified category of contributing causes. Regulations and
permits was identified as a root cause of noncompliance under all
statutes except CERCLA. The specific cause facility unaware of the
applicability of a regulation was identified only for noncompliance
events under the CAA and TSCA. On the other hand, the specific
cause ambiguous or inconsistent federal regulations generally was
identified for noncompliance events under EPCRA and RCRA.
Specific causes in the
Regulations and Permits
category that were identified
frequently include:
Facility unaware of applicability of
a regulation 52%
Inconsistent or contradictory
interpretation of federal
regulations 19%
Ambiguous federal
regulations
14%
22
-------
In cases in which facilities were unaware of the applicability of a
regulation, other root causes of the noncompliance identified were
human error and procedures. When ambiguous or inconsistent
federal regulations was identified as a specific cause, communication
difficulties between facility and regulatory agencies was the only
associated root cause identified.
Human Error
The category human error was identified as frequently as regulations
and permits as the root cause of noncompliance. Specific causes in the
human error category were identified by respondents as either
individual responsibility or professional judgment or inexperience, lack of
knowledge, lack of technical expertise. The human error category was
identified as a root cause of noncompliance under all statutes except
CERCLA.
In four cases, individual responsibility or professional judgment
was identified as the sole cause of a noncompliance event. That
cause was the only one for which more than one respondent did not
identify another root or contributing cause for a noncompliance
event. Although individual responsibility or professional
judgment was identified in those cases as the sole cause of
noncompliance, three of the facilities reported that they had
implemented changes in their procedures to prevent recurrence of
the noncompliance event.
When individual responsibility or professional judgment was
identified as a root cause, procedures frequently was identified as an
associated root or contributing cause.
Lack of training and communication difficulties seldom were
identified as contributing causes when human error or procedures
were identified as the root cause. That circumstance is surprising,
given the widely held opinion that training and improved
communication are effective ways to reduce human error.
Procedures
Procedures was identified as a root cause of 17 percent of the
noncompliance events. Specific causes in the procedures category
identified most frequently were operating procedures not followed and
no written operating procedures available. The procedures category was
identified as a root cause of noncompliance under five environmental
statutes: the CAA, CERCLA, the CWA, RCRA, and TSCA.
Other root causes associated with the procedures category include
human error, regulations and permits, communications difficulties,
and procedures.
In cases in which procedures was identified as a root cause,
procedures were also identified frequently as a contributing cause
as were compliance monitoring and management.
Specific causes in the
Human Error category
that were identified
frequently include:
Individual responsibility
or professional
judgment 67%
Inexperience, lack of
knowledge, lack of
technical expertise 3 3%
Specific causes in the
Procedures category that
were identified frequently
include:
Operating procedure
not followed 47%
No written operating
procedures available 29%
Ti
-
23
-------
Equipment Problems
Equipment problems was identified as a root cause of 10 percent of
the noncompliance events. The specific causes identified in the
equipment problems category included design or installation,
equipment maintenance, and ordinary wear-and-tear. For 50 percent
of such noncompliance events, more than one equipment problem
was identified. The table below lists the specific types of equipment
involved in noncompliance events. Other root causes associated
with equipment problems included external circumstances and
procedures.
Only two environmental statutes, the CWA (70%) and RCRA (30%),
were identified in connection with noncompliance events caused by
equipment problems.
Specific Equipment Problems
Equipment Type
Wastewater treatment system
Tanks, vessels, and reactors
Curbing and dikes
Function Lost
Gross volume that provided equalization
Surge capacity (wastewater equalization)
Containment
Specific causes in the
Equipment Problems
category that were identified
frequently include:
Design or installation 40%
Equipment maintenance 20%
Ordinary wear-and-tear 20%
External Circumstances
External circumstances was identified as a root cause of 7 percent of the
noncompliance events. For 72 percent of such noncompliance events,
contracted services such as haulers or handlers was identified as the specific
cause. In those cases, procedures frequently was identified as a related
root cause or contributing cause.
Only three environmental statutes, the CWA (72%), the CAA (14%),
and RCRA (14%), were identified in association with noncompliance
events caused by external circumstances.
Communications Difficulties
Communications difficulties was identified as a root cause of 7
percent of the noncompliance events. Specifically, difficulties between
facility and regulatory agency was identified frequently. When
difficulties between the facility and regulatory agencies was identified as
a root cause, regulations and permits frequently was identified as an
associated root cause.
The category communications difficulties was identified as a root
cause of noncompliance under four environmental statutes, TSCA
(57%), the CAA (14%), the CWA (14%), and RCRA (14%).
Specific causes in the
External Circumstances
category that were identified
frequently include:
Contracted services, such
as haulers or handlers 72%
External phenomenon 14%
Sitewide power failure 14%
Specific causes in the
Communications Difficulties
category that were identified
frequently include:
Between facility and
regulatory agencies 57%
Between employees 29%
24
-------
Contributing Causes
Although rarely identified as root causes of noncompliance,
management and compliance monitoring were identified frequently
as contributing causes of noncompliance events (see the figure on
page 20). Management was identified most often as a contributing
cause in cases in which regulations and permits or procedures was
identified as a root cause of a noncompliance event. Compliance
monitoring was identified frequently as a contributing cause in
cases in which procedures was identified as a root cause.
25
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ENVIRONMENTAL MANAGEMENT SYSTEMS
AND COMPLIANCE
Chapter Highlights
Survey responses indicate that there is a strong relationship between
the implementation of EMSs and compliance. Responses also suggest
that comprehensive EMSs—with elements working together and
continually evaluated—should improve compliance.
• The majority of responses identified environmental audit
programs; corporate policies, goals, targets, and guidelines; and
Responsible Care® as management methods that have a strong
influence on environmental performance.
• Among the respondents, 78 percent modified their EMSs in
response to noncompliance.
• Among the respondents, 41 percent stated that Responsible
Care® or another EMS would have contributed to the prevention
of the noncompliance.
• Among actions taken in response to noncompliance, 70 percent
are considered by the project team to be relevant to an EMS.
26
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Management
Review
Continual
Improvement
Discussion
Increasingly, private- and public-
sector organizations are using
EMSs to manage (to control and
minimize) the environmental
effects of their activities. An EMS
is an organized process established
by policy to integrate planning,
implementation, corrective action,
and management review. An
EMS specifies the structure,
personnel, procedures, practices,
and resources that will play a role
in controlling and minimizing the
effects of a company's operations.
EMSs typically include continuous
improvement through a "plan-do-check-act" cycle, as the figure to
the right illustrates.
An important component of an EMS is to routinely evaluate and
improve the entire EMS program, which, in doing so, requires
management attention. Because an EMS, by itself, cannot assure
compliance, management and employee awareness and participation
are crucial to help achieve and maintain compliance.
Survey recipients were not provided a definition of an EMS to use as
a guide in completing the survey. It is understood that different
organizations have diverse views about the definition and scope of
an EMS. This chapter presents the findings of the survey related to
EMSs. In particular, this chapter illustrates the strong relationship
between EMSs and compliance.
Background
In 1988, CMA launched Responsible Care® in response to public
concerns about the manufacture and use of chemicals. Through
Responsible Care®, member companies are committed to the
support of a continuing effort to improve the industry's responsible
management of chemicals. Responsible Care® is an obligation of
membership in CMA and requires member companies to:
• Improve performance in health, safety, and environmental
quality
• Listen and respond to public concerns
• Assist each other in achieving optimal performance
• Report their progress to the public
Environmental
Policy.
Planning
Implementation
27
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The Guiding Principles—the philosophy of Responsible Care®—outline
each member company's commitment to environmental, health, and
safety responsibility in managing chemicals. Six Codes of Management
Practices, which are the heart of Responsible Care®, outline practices that
cover virtually every aspect of the manufacturing, transportation, and
handling of chemicals. CMA subsequently developed the Responsible
Care® Management System Verification concept, which organized the
six codes into a single system.
For its part, EPA is particularly interested in the extent to which EMSs
contribute to improved compliance and pollution prevention.3
Specifically:
• EPA believes that implementation of an EMS has the potential to
improve an organization's environmental performance and
compliance with regulatory requirements
• EPA encourages the use of EMSs that focus on improved
environmental performance and compliance as well as source
reduction (pollution prevention) and system performance
At the time of preparation of this report, EPA does not base any
regulatory incentives solely on the use of EMSs or EMS certifications.
Appendix E provides summary discussions of three EMS initiatives:
Responsible Care®, ISO 14001, and the National Enforcement
Investigations Center (NEIC) EMS Criteria.
EMS Findings
The survey included several questions about EMSs. The questions
addressed (1) the extent to which Responsible Care® or another EMS
was in place before the noncompliance event and (2) whether the
system had been modified after the noncompliance event. The survey
asked questions about discrete elements and characteristics of EMSs;
however, determining the extent to which those elements and
characteristics are integrated and linked to form an active,
comprehensive EMS was outside the scope of the survey.
EMS elements
An EMS consists of elements and functions important to active environmental management.
Although several EMS guidelines exist, most feature all or most of the following elements:
• Policy • Monitoring and measurement
• Environmental aspects • Corrective and preventive action
• Audits • Compliance requirements
• Management review • Objectives
• Documentation • Training
• Emergency response • Communication
3 On March 12, 1998, EPA published a notice in the federal Register (63 F.R. 12094-12097) to communicate its
views about EMSs.
28
-------
EMS observations derived from the surveys are organized as follows:
• Implementation status
• Changes in response to noncompliance
• Effect on compliance
Implementation Status
Rather than including a particular definition, the survey inquired
broadly about various programs or systems that would include a
number of EMS activities. All facilities that responded to the questions
employed more than one of the environmental management methods
described below.
Use and Influence of Various Environmental Management Methods
Environmental
Management Method
Environmental Audit Program
Corporate Policies, Goals,
Targets, and Guidelines
Responsible Care®
Management System
Other EMS
Facilities Having Method in
Place for:1
> 5 years
78%
85%
66%
4%
< 5 years
7%
11%
26%
22%
Average Rank of Influence on
Environmental Performance2
2.2
2.5
2.9
4.4
' The term "years" refers to the number of years the environmental management method had been in place at the time of the survey.
1 Numbers in this column are the average rankings on a scale of 1 to 8, with 1 indicating greatest influence and 8 indicating least influence.
Respondents ranked environmental audit programs and corporate
policies, goals, targets, and guidelines as having the greatest influence
on environmental performance. The rankings may reflect the longer
period of time during which a particular environmental management
method had been in place, compared with Responsible Care® or
another EMS. Alternatively, the rankings may indicate the extent to
which the various methods are directed toward compliance (for
example, audits), rather than broader measures of environmental
performance (for example, Responsible Care®).
The survey asked detailed questions about the status of the facility's
EMS (Responsible Care® or another EMS) at the time of
noncompliance and how the EMS may have been changed after the
noncompliance event occurred. Responses to those questions
generally indicated widespread implementation of EMS elements at
the time of noncompliance. For example, 15 percent of respondents
had implemented all elements identified in the survey, and 70 percent
of respondents had implemented at least 15 elements of an EMS (of the
25 described in the survey) at the time of noncompliance.
The figures that follow summarize the elements of an EMS that were
identified most and least frequently to have been in place at the time the
noncompliance event occurred. The elements most frequently
Environmental audit
programs; corporate
policies, goals, targets, and
guidelines; and Responsible
Care® were identified as
management methods that
have a strong influence on
environmental performance.
T"'
29
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identified as in place were environmental reporting, compliance audits,
communication, and emergency response procedures. The widespread
implementation of environmental compliance audits at the time of
noncompliance is consistent with responses that environmental audit
programs had been in place at most facilities surveyed for more than five
years and were perceived to have the greatest influence on the facilities'
environmental performance. In contrast, the elements least frequently
identified as in place at the time of noncompliance were EMS
documentation, EMS audits, EMS record keeping, and EMS procedures.
EMS Elements or Features Most Frequently in Place at Time of Noncompliance
Percent of
Respondents1
Reporting: "There is a system in place to ensure environmental reports required
by federal and state regulations are prepared routinely and submitted on a
timely basis."
Environmental Compliance Audits:
• "...are conducted by persons independent of the facility unit that is
the subject of the compliance audit."
• "...are conducted at least every 3 years."
• "...results are reported directly to facility management."
• "A formal review is in place for follow-up of exceptions noted in
inspections or audits and supported by management review."
Internal Communication: "Staff are encouraged to communicate environmental
issues and concerns directly with top management and/or environmental
managers."
Emergency Response: "Procedures are established to identify the potential
for and response to emergency situations."
89%
91%
88%
88%
88%
85%
85%
EMS Elements or Features Least Commonly in Place at Time of Noncompliance
Percent of
Respondents1
EMS Documentation: "The facility has developed a written description of the
facility EMS that describes its organization and functional structure and elements."
EMS Audits:
• "The integrity and efficacy of the EMS are periodically reviewed and
revisions are made based on this review."
• "Periodic EMS audits are conducted at the facility."
EMS Record Keeping: "The facility has designated a point of contact for
records related to the EMS."
Environmental Procedures: "There is a system in place to review and update
environmental procedures periodically."
42%
50%
55%
62%
62%
'Percent of respondents who indicated that the element was part of the facility's EMS at the time of noncompliance
30
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Changes in Response to Noncompliance
The survey asked respondents to identify EMS elements that were
clarified or added after the noncompliance event occurred. Twenty-one
(78%) facilities modified their EMSs in some manner. Most clarifications
and additions involved implementation, operation, or accountability.
Otherwise, there were no notable trends, with all other clarifications and
additions distributed broadly among the elements listed in the survey.
Clarifications and additions were made to Responsible Care® and other
EMSs with approximately the same frequency. The frequency with
which modifications were made to EMSs may have occurred because
Responsible Care® and other EMSs were evolving during the period in
which the noncompliance events occurred. Elements of an EMS may
have been in place at a respondent's facility, but not understood by
employees to be part of an EMS. The frequency of modification indicates
a trend of modifying EMSs to minimize the recurrence of noncompliance
events.
The majority of
respondents modified
their EMS in response
to noncompliance.
Survey responses indicate a
strong relationship between
the implementation of
EMSs and compliance.
Environmental Impact Inventories . . .
An impact inventory is an assessment of how an organization's activities (aspects) interact with the
environment. An impact inventory generally is regarded as a crucial element of most EMS planning
activities. Most respondents (63%) that had conducted impact inventories stated that the
inventory had a positive effect on compliance.
Changes made in an EMS after a noncompliance event occurred also
were evaluated in light of the specific actions taken in response to the
noncompliance event. The project team classified each of the seven
categories of actions taken, described in Chapter 2, as relevant or not
relevant to EMS activities or elements. For example, if a facility revised
a training program in response to a noncompliance event, that action
was considered relevant to the EMS because training is a key element
of an EMS. The project team considered all actions taken, except for
those categorized as equipment design, operation and maintenance,
and regulations and permits, to be relevant to an EMS. The majority
(71%) of the actions taken in response to noncompliance were deemed
relevant to an EMS. The figure on the next page shows the distribution
of the actions relevant to an EMS and other actions taken in response to
noncompliance.
Effect on Compliance
Although implementation and maintenance of a fully functional EMS
does not guarantee 100 percent compliance with environmental
requirements, an EMS can provide approaches, context, and
structure to facilitate identifying problems and potential problems
and addressing them in a timely manner. Several survey findings
indicate that respondents consider the EMS such a tool. First, the
majority of responses identified environmental audit programs,
corporate policies, goals, targets, and guidelines, and Responsible
While an EMS plays a
large role in preventing
noncompliance,
implementation and
maintenance of a fully
functional EMS does not
guarantee 1 00 percent
compliance with
environmental requirements.
Facilities may benefit from
exploring the relationship
between the root causes of
noncompliance
and the facility's EMS.
?'
31
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Distribution of Actions Relevant to and
Not Relevant an EMS
Actions Not
Relevant to an EMS
Management
4%
Compliance
Monitoring and Training
Auditing 12%
9%
Actions Relevant to
an EMS
The majority (71 %) of
actions taken in
response to
noncompliance are
considered relevant to
an EMS
Care® as management methods that have a strong influence on
environmental performance. Second, 71 percent of respondents took
EMS-related actions to prevent recurrence of noncompliance. For
example, the most common actions taken—changes in procedures and
policies—are viewed almost universally as integral parts of any EMS.
Finally, several of the types of causes identified by respondents suggest
a strong relationship between compliance and the existence of an EMS.
For example, the root (human error and procedures) and contributing
(management, procedures, and compliance monitoring) causes for
noncompliance events identified by most respondents are linked
directly to fundamental concepts of an EMS, such as commitment on
the part of management, clearly communicated procedures, and
auditing.
The important relationship between EMSs and compliance is
supported further by the finding that 41 percent of the respondents
stated that Responsible Care® or another EMS would have
contributed to the prevention of the noncompliance. Those
respondents typically had implemented EMS activities, such as
employee training, clarification of facility procedures, and
modification of facility auditing practices, in response to
noncompliances events. Although the remaining 59 percent of
respondents stated that Responsible Care® or another EMS would
not have contributed to the prevention of the noncompliance, 79
percent of these respondents also identified actions intended to
prevent recurrence of the noncompliance that are relevant to an
EMS. The responses suggest that EMSs may play a larger role in
preventing noncompliance than some respondents indicated.
Among respondents,
41 percent stated that
Responsible Care® or
another EMS would
have contributed to the
prevention of the
noncompliance.
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Would Responsible Care® or another EMS—if implemented before the occurrence of the
noncompliance—have contributed to prevention of the incident?
Some respondents stated:
"A review of cause of exceedances would have given a better understanding and possible
quicker solution to identify remedies."
"The existence of an EMS would have made facility personnel aware of the program
requirements and the incident would not have occurred."
"The formal structure of the management systems implemented to meet Responsible Care®
commitments would have increased the probability of clear communication of requirements, and
the likelihood that internal compliance reviews would have identified remaining weaknesses for
self-correction prior to the EPA inspection."
"A better system would have been in place to assure compliance with all permitting requirements
rather than relying on one person."
33
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RESPONDENTS' PERSPECTIVES ON
IMPROVING COMPLIANCE
Chapter Highlights
Respondents perspectives on traditional and innovative approaches
to improving compliance include:
• Respondents identified increased employee involvement,
improvement of the facility's management system, more clearly
defined commitment on the part of management, and improved
understanding of regulations as the most effective actions
industry could take to improve compliance.
• Respondents identified tools developed by the facility, facility
employees and corporate staff, and trade associations as the most
useful sources of compliance assistance, indicating the industry's
historical reliance on in-house support.
• Respondents recommended that government work with
industry to provide more technical assistance, including
guidance, documents, self-audit check lists, logic or applicability
flowcharts, and workshops—ideally for each new rule.
• Respondents recommended a range of policy and regulatory
changes, including the development of "plain language" rules,
pilot testing of new rules, consolidation of overlapping
regulatory requirements, and reduction of record keeping and
reporting requirements.
• Respondents suggested that self-audits, third-party audits, EMS
audits, or other forms of self-monitoring, potentially coupled
with penalty relief, be used as alternatives to traditional
compliance inspections.
• Among the respondents, 50 percent suggested that EPA reduce
the frequency of compliance inspections for facilities that have
good compliance records.
• Among the respondents, 66 percent participate in federal or state
voluntary programs; respondents believe that these programs
primarily focus on pollution prevention and that participation in
them does not necessarily improve compliance.
34
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Discussion
The survey asked questions about traditional and innovative
approaches to improve compliance. The first section below focuses
on respondents' perspectives on compliance assistance activities and
regulatory changes that could improve compliance. The majority of
those responses focus on EPA-related activities. This chapter also
includes additional ideas about improving environmental compliance
identified by individual members of the project team. The second
section summarizes respondents' views on a range of topics related
to compliance and enforcement activities, including:
• Industry actions for improving compliance
• Compliance assistance sources
• Alternatives to traditional compliance inspections
• Incentives that reward compliance
• Effect of voluntary programs on improving compliance
Recommendations and Ideas for Compliance Assistance and
Regulatory Change
The respondents' recommendations were grouped in four
categories, according to the subject of the change recommended:
• Compliance assistance activities
• Changes in EPA policy
• Regulatory changes
• Statutory changes
The categories were divided further according to the applicable
statute. The respondents' recommendations and project team
members' ideas that can be applied under any statute are provided
below. Appendix F presents respondents' recommendations
relevant to specific statutes.
Compliance Assistance Activities
Respondents suggested that EPA undertake the following compliance
assistance activities for all applicable environmental statutes:
• Provide technical assistance in meeting the requirements of
existing and new regulations. Specific examples of technical
assistance suggested include guidance documents, regulation-
specific self-audit check lists, logic guides, applicability flow
charts, seminars or workshops, and on-site compliance or
technical assistance.
In addition, individual members of the project team presented the
following ideas:
• Develop industry-sponsored training on "how chemical plants
35
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work" for staff of regulatory agencies (for example, rule writers
and inspectors).
• Develop an industry-EPA personnel exchange program.
• Develop an inspection program under which technical assistance
inspections are conducted routinely in advance of traditional
enforcement inspections, particularly in the case of new rules.
Changes in EPA Policy
Respondents suggested the following changes in EPA policy:
• Issue compliance assistance tools with each new final rule.
• Modify EPA's audit policy to provide for immunity from penalties,
rather than mitigation, for disclosures of noncompliance.
• Allow facilities a "grace period" for complying with new
regulations.
• Designate a single EPA contact to work with each facility to
coordinate EPA regulatory activities and provide assistance.
• Allow and encourage EPA inspectors to (1) provide technical
assistance and (2) mitigate or omit penalties for noncompliance
events that are addressed in a timely manner.
• Draft clear, "plain-English" rules and, as needed, include logic
diagrams.
• Emphasize the collection of required information rather than
enforcement activities in cases in which noncompliance events
related to submittal of reports are discovered.
• Redirect inspectors from a focus on individual noncompliance
events to a more comprehensive evaluation of the effectiveness of
a facility's systems for protecting the environment.
• Improve coordination between EPA and states, particularly with
regard to the interpretation of regulatory requirements.
• Increase the use of compliance assistance programs to help the
regulated community understand and implement regulatory
requirements.
• Create focus groups representing all stakeholders during early
stages of revision of rules.
In addition, individual members of the project team presented the
following ideas:
• Pilot-test a program similar to the Occupational Safety and
Health Administration's (OSHA) "Nationwide Quick-Fix
Program" (OSHA Instruction CPL 2.112, August 2,1996), which
offers reductions of penalties to employers that immediately
abate hazards identified during an OSHA inspection.
36
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• Provide compliance assistance to the regulated community and
target compliance inspections on those facilities that do not
request or participate in compliance assistance activities.
• Request that rule writers, rather than enforcement and compliance
assistance staff, interpret rules.
Regulatory Changes
Respondents suggested the following changes in federal environmental
regulations:
• Request that rules focus on performance rather than prescribed
steps (that is, establish performance standards and allow
industry the opportunity to meet the standards through
adoption of those alternatives it chooses).
• Work with industry to pilot-test the feasibility of new rules before
they are promulgated.
• Consolidate overlapping regulatory requirements.
• Reduce record keeping and reporting requirements.
In addition, individual members of the project team presented the
following ideas:
• Incorporate all requirements in a single rule to minimize cross-
referencing of requirements among rules
• Change permit modification procedures under the various
federal environmental regulations so that the correction of errors
in calculation is a minor modification (like the correction of
typographical errors), rather than a major modification.
Other Compliance and Enforcement Perspectives
Respondents provided their views on a range of topics related to
traditional and innovative compliance and enforcement activities.
Industry Actions for Improving Compliance
The survey asked respondents to rate 13 general actions industry could
take according to their helpfulness in improving compliance. The four
actions that were identified as most helpful to industry in improving
compliance are:
• Increasing employee involvement
• Improving facility EMS
• More clearly defining management commitment
• Improving the understanding of regulations
These actions address functions important to EMS elements and
validate industry's perspectives on the importance of EMSs. The
"helpfulness scores" suggest that industry can improve compliance
by strengthening, integrating, and linking EMS elements.
37
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The table below presents "helpfulness scores" for all areas evaluated
by the respondents.
Actions That Improve Compliance
Increased employee involvement
Improved facility management system
More clearly defined management commitment
Improved understanding of the regulations
Improved tracking system
Increased facility management involvement
Improved intrafacility communication
Improved record keeping procedures
More clearly defined responsibilities
Improved corporate/facility communication
More modern equipment
Increased number of employees
Improved access to EPA technical experts
Helpfulness Score1
Scale: 1 0 = Most Helpful
1 = Least Helpful
7.3
7.2
6.9
6.8
6.7
6.4
6.3
6.2
6.2
5.3
5.3
4.9
4.7
1 Average helpfulness score
Compliance Assistance Sources
The survey asked respondents to rate for usefulness, on a scale 1 to 5,
15 types of compliance assistance sources that the facility has used.
The three sources most frequently identified are:
• Tools developed by the facility
• Facility employees (including corporate staff)
• Trade associations
The identification of the above sources indicates that facilities favor
materials developed by industry. This finding is supported by
responses that stated that lessons learned from noncompliance events
typically are shared with sister facilities, corporate offices, and trade
associations, thereby enabling those organizations to provide
effective compliance assistance to one another.
The least useful sources identified by respondents were universities
and vendors, perhaps because such organizations typically do not
provide compliance assistance to large facilities. Industry uses those
resources for other purposes, such as obtaining information about
pollution prevention. Assistance from federal employees also
received relatively low scores for usefulness. The desire to protect
Respondents
identified tools
developed by industry as
the most useful sources
of compliance assistance.
38
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anonymity may limit industry's reliance on EPA for compliance
assistance. The low rating of EPA also may reflect the relatively short
time that EPA has been providing active compliance assistance.
Similarly, the relatively low ratings assigned to state compliance
assistance organizations and the Internet may derive in part from the
relative novelty of those sources. In addition, state compliance
assistance programs tend to focus on small businesses, while 81
percent of the facilities participating in the project have more than 100
employees.
The table below summarizes the ratings respondents assigned to
various compliance assistance sources.
Source of Compliance Assistance
Tools developed by the facility
Facility employees (including corporate staff)
Trade associations
Other facilities
Conferences
Consultants
Agency hotlines
Federal publications
State publications2
Internet
State employees
State compliance assistance organizations
Federal employees2
Vendors and suppliers2
Universities2
Usefulness Score1
Scale: 5 = Very Useful
1 = Not Very Useful
4.1
4.0
3.8
3.6
3.6
3.6
3.4
3.4
3.4
3.3
3.2
3.0
2.8
2.6
2.2
' Average usefulness score
2 Fewer than 20 respondents scored this source
Alternatives to Traditional Compliance Inspections
The survey asked what industry evaluation methods could be used as
substitutes for traditional compliance inspections. Approximately 60
percent of respondents answered the question. Almost all suggested
alternatives involving self-audits, third-party audits, EMS audits, or
other forms of self-monitoring to verify compliance. The relative
uniformity of the responses may have been a result of the wording of
the survey question, which offered "compliance or EMS audits" as
examples. Nevertheless, many respondents qualified their answers.
One respondent suggested that EPA inspectors visit the facility
Respondents
suggested that self-audits,
third-party audits, EMS
audits, or other forms of self-
monitoring be used as
alternatives to traditional
compliance inspections.
£3^^^»fes»^^
39
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within a reasonable time after the self-audit report is submitted to verify
that any deficiencies have been corrected. Another respondent
suggested that companies that have third-party audit programs
undergo formal inspection by EPA less frequently than those that do not
have such programs. Three respondents stated that recognition by EPA
of auditing programs should be accompanied by elimination of penalties
for identified and corrected violations; two stated further that
corrections should be made within a reasonable period of time or "grace
period." Those responses, and similar responses to other questions,
suggest a view that EPA's current audit policy does not grant adequate
relief from penalties.
Incentives That Reward Compliance
The survey asked what incentives EPA could use to acknowledge or
reward sustained compliance. No detailed responses were provided.
However, respondents suggested four categories of incentives:
• Reduce the frequency of inspections
• Reduce or eliminate penalties for deficiencies identified during self-
audits
• Provide public recognition
• Pursue "fast track" environmental permitting
Approximately 50 percent of respondents suggested that EPA reduce
the frequency of compliance inspections for facilities that have good
compliance records.
Effect of Voluntary Programs on Improving Compliance
The survey asked whether a facility was participating in a state or
federal voluntary program. If so, the respondent was asked to
characterize the program's effect on compliance. Two-thirds (66%) of
respondents stated that their facilities were involved in federal or state
voluntary programs. Examples of federal voluntary programs
mentioned by respondents are EPA's 33/50 Program, Project XL,
Climate Wise, and Green Lights. Examples of state voluntary programs
are the Louisiana Environmental Leadership Program and Clean Texas
2000. Respondents representing facilities involved in such a program
generally said the program had no effect on compliance or did not
comment on the program's effect. Two notable exceptions were the
OSHA Star program, which was commended by one respondent for its
positive effect on compliance. A second comment concerned the
Consolidated Fugitive Monitoring Rule established by the Louisiana
Department of Environmental Quality and EPA Region 6; the
respondent stated, "With multiple fugitive monitoring regulations to
comply with, this program allows the facility to comply with the
reporting and record keeping requirements of the most stringent fugitive
monitoring programs."
Respondents
participating in
federal or state
voluntary programs
do not believe that
participation in those
programs improves
compliance.
40
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One reason some respondents believe that voluntary programs do
not help improve compliance is that most voluntary programs
focus on pollution prevention, rather than specific compliance
issues. Participation in such a program does not necessarily
change a facility's compliance obligations, although it could (for
example, in a case in which a facility reduced its use or emissions
of a substance to the point that it fell below the applicability
threshold of a rule). Many respondents representing facilities that
were not involved in voluntary programs stated that all their
limited environmental management resources are required to
attain and maintain compliance.
WWW Site
More information about EPA's voluntary programs is
available on the Internet at:
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Chapter 5
RECOMMENDATIONS
Chapter Highlights
Industry should consider the following actions to improve compliance
through enhancements of EMSs:
• Ensure that all EMS elements are in place and all employees understand
that the elements are part of the facility's EMS.
• Implement a program that promotes high levels of awareness of and
commitment to the EMS among employees at all levels.
• Increase awareness among management and employees of the central role that
a comprehensive EMS can play in achieving and maintaining compliance.
• Focus efforts on identifying more opportunities for rigorous
implementation and evaluation of EMSs.
• Establish accurate, standard operating procedures that all affected
employees can understand.
• Train employees to ensure that new and modified operating procedures
are implemented properly.
• Conduct root cause analyses focused on an exhaustive and diligent identification
of all causes of noncompliance to properly identify long-term solutions.
EPA should consider the following actions to promote compliance with regulations:
• Articulate new regulations more clearly.
• Work with state agencies to ensure that regulations are interpreted
consistently.
• Continue compliance assistance and outreach activities.
• Consider the development of compliance assistance tools, such as plain-
English guides for every new rule.
• Provide more incentives for industry to disclose violations.
Individually, and working together, EPA and various industry sectors should pursue
additional root cause analyses of noncompliance to better understand the findings and
recommendations discussed in this report. Such analyses might focus on:
• Understanding why and in what situations violations occur at facilities
with EMSs.
• Looking more carefully at the "human error" category of causes used in
this report.
• Involving, at the design stage of the analysis, a statistician and social
psychologist.
• Studying noncompliance at small (less than 100 employees) companies.
• Conducting more research through discussions between EPA and
industry to more fully understand the relationship between particular
violations and appropriate corrective actions.
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Discussion
This chapter presents recommendations for EPA and industry to
consider that may lead to improved compliance with environmental
regulations. The recommendations are based on: (1) observations
about root causes and actions taken in response to noncompliance
events, as presented in Chapter 2; (2) trends in noncompliance
related to specific statutes, as described in Appendix D; (3) industry
perspectives on improving compliance, as presented in Chapter 4;
(4) observations regarding EMS related actions taken to return to
compliance, as presented in Chapter 3; and (5) survey responses
related to beneficial effects of the establishment and maintenance of
EMSs on environmental performance, as presented in Chapter 3.
Recommendations included in the first section of this chapter
generally focus on EMS improvements. Recommendations for EPA
and industry to promote compliance, both generally and in
connection with particular statutes, also are provided.
Strengthen Awareness and Implementation of EMSs
Recommendations provided in this chapter are based on survey
findings indicating that EMSs play a larger role in improving
compliance than often is recognized. Survey responses also indicate
that further integration of EMS elements into an EMS framework
should result in improved compliance. For example, one respondent
stated: "The formal structure of the management systems
implemented to meet Responsible Care® commitments would have
increased the probability of clear communication of requirements,
and the likelihood that internal compliance reviews would have
identified remaining weaknesses for self-correction prior to the EPA
inspection." Recognizing that EMSs are a tool to improve
compliance is a first step toward improving compliance.
Development and maintenance of a comprehensive, well-
integrated and clearly articulated system should contribute
significantly to improvements in compliance as sought by industry
and regulators.
A key method of ensuring that an EMS is viewed consistently and
integrated into the daily operation of the facility is to encourage a
high degree of awareness of it and commitment to it among all
employees. Awareness and commitment can be achieved, in part,
by clearly conveying top management commitment to environmental
performance including compliance, by improving communication
between management and employees and by appropriately
dividing responsibility among environmental professionals and
those with day-to-day operating responsibilities. Although
maintaining effective communication and identifying clearly
defined responsibilities can be challenging, a fully functional EMS
appears to be an effective way to facilitate long-term compliance.
All employees should
be aware of and
committed
to the facility's EMS.
Increased awareness of
the relationship
between compliance
and the EMS
will fortify efforts to
sustain a
comprehensive,
integrated EMS.
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Increased awareness of the relationships between compliance and
the EMS will fortify efforts to sustain a comprehensive, integrated
EMS. To promote long-term compliance, industry should focus
efforts on identifying opportunities for more rigorous implementation
and evaluation of EMSs.
Considering the findings of the survey related to EMSs, further
inquiry into the benefits of implementing EMSs is warranted. One
possible follow-up investigation could focus on the 41 percent of
respondents who stated that an EMS would have helped prevent the
noncompliance event. Those respondents could be asked to provide
additional information about how their facilities' EMSs help maintain
compliance. Certain EMSs also could be used as case studies to help
those facilities that do not have a fully functional integrated EMS.
Improve or Create Procedures Reinforced by Training
Human error and procedures were frequently identified as root causes. In
many cases, both causes were identified for individual noncompliance
events. Specifically, respondents identified failure to follow operating
procedures as a root cause of many noncompliance events, especially
those occurring under the CAA, CERCLA, the CWA, and RCRA.
Human error and procedures often were identified as the root causes of
noncompliance events related to reporting, operation and maintenance,
and record keeping. Reporting, operation and maintenance, and record
keeping typically are process-oriented activities that require step-by-step
instructions or clearly articulated procedures. Therefore, establishing
accurate, standard operating procedures that can be easily understood
by employees may help reduce the frequency of occurrence of
noncompliance events caused by human error or procedures.
Changes in procedures alone, however, may not fully address the
causes of noncompliance. The actions taken in response to
noncompliance identified in survey responses indicate the
importance of training for properly implementing new or modified
procedures. Training was identified as the third most frequently
taken action (12%) in response to noncompliance events.
Employee training, awareness, and competency are important elements
of any EMS. Because training was not identified frequently as a root or
contributing cause, respondents may not have considered their training
program a problem related to their EMSs. Facilities should reconsider the
extent to which training is integrated into their EMSs. Doing so involves
two steps. First, everyone in an organization should be trained in
environmental responsibilities, tailored to the nature and extent of the
potential environmental impacts of the employee's job. Second, the
organization should document that all employees have received the type
and level of environmental training appropriate for their jobs. The
knowledge, skills, and abilities (competencies) needed to understand
environmental impacts and regulatory requirements must be identified
and developed. Finally, facilities should work with contractors who
share their commitment to fully functional EMSs.
Employees should
be trained to ensure
that new and modified
operating procedures are
properly implemented.
Operating procedures
that can be understood
by all affected employees
should be established.
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Promote and Encourage Root Cause Analyses
The information and ideas gained from the partnership between EPA
and industry to study the effect of root cause analysis on compliance
provide new opportunities to improve compliance. Through such
efforts, EPA and industry have acquired unique perspectives on how
environmental regulations are understood and implemented at
individual facilities. Equipped with such knowledge, EPA can
continue to improve the effectiveness of its regulatory programs and
compliance assistance efforts. Industry, for its part, can review its
resource allocations to address root causes of noncompliance, thereby
improving return on environmental spending. Working together,
EPA and industry can pursue additional root cause analyses of
noncompliance to support improved environmental performance,
including compliance with environmental requirements.
An important consideration in using root cause analyses to improve
compliance is to identify all causes related to an incident of
noncompliance. Identifying a single cause without evaluating all
potential causes of the noncompliance may lead a facility to adopt an
ineffective solution. In most (94%) cases, several causes were
identified for an incident of noncompliance. For example, when
regulations and permits was identified as a root cause of
noncompliance, it typically was associated with other causes such as
human error, management, and procedures. The likelihood is great
that any given noncompliance event has more than one cause. The
accurate identification of all causes of noncompliance is essential to
identifying and implementing long-term corrective measures.
When conducting root cause analyses, it is important to distinguish
between what first may appear to be the cause of noncompliance
from the true root cause(s) of the noncompliance. For example, 71
percent of the survey respondents that identified human error as a root
cause of a noncompliance event implemented modifications of their
existing procedures to prevent recurrence of the noncompliance.
However, 90 percent of these respondents did not identify procedures
as a root cause of the noncompliance event. This survey finding
indicates that unclear or outdated procedures, rather than human
error, may have been a root cause. (Alternatively, the facility may
have revised the relevant procedures simply for lack of any other
concrete action to take, to avoid the appearance of not taking any
action.) Addressing an apparent cause of noncompliance may not
provide long-term solutions to noncompliance. Any application of
root cause analysis should focus on an exhaustive and diligent
identification of the true causal factors that should yield long-term
solutions.
Root cause
analyses should focus
on an exhaustive and
diligent identification of
all causal factors to pro-
perly identify long-
term solutions.
45
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Outreach Through the Internet
ChemAlliance
EPA has funded a compliance assistance center for the chemical industry called
ChemAlliance. The goal of ChemAlliance is to provide industry with easy access
to EPA's regulatory information and a compliance assistance network.
ChemAlliance promotes the exchange of information and technology transfer
among its users. Available through ChemAlliance are examples of EPA's efforts
to improve compliance and environmental performance, including:
• Compliance Improvement Tool (CIT): This tool provides an annotated list of
compliance assistance resources applicable to the chemical industry sector.
• Inspection Tool for the Hazardous Organic NESHAP (RON): Volume I -
Overview of Emission Points, Control Technology and HON Provision: This tool
identifies sources of hazardous organic emissions regulated under the Clean Air
Act (CAA) NESHAP requirements.
• Process-Based Self Assessment Tool for the Organic Chemical Industry: This tool
provides guidance on performing multi-statute self-assessments to detect and
correct noncompliances.
• Unified Air Toxics Website (UATW): EPA Rules & Implementation Information
Pages: More than a hundred different air toxics related rule information pages
have been developed.
ChemAlliance provides information through the World Wide Web site:
CMA Outreach
In September 1995, CMA instituted a compliance assistance
program to develop tools to assist its members in complying with
federal regulations. Each compliance package includes a guidance
document, training materials, and a self-assessment check list. Other
trade associations may collaborate on the tools. The relevant
regulatory agency typically reviews the tools in draft, and in some cases has co-issued
them. Under the program, compliance packages have been developed on such rules as:
• Resource Conservation and Recovery Act (RCRA) Subpart CC
• CAA 112(r) Risk Management Plan
• The Hazardous Organic NESHAP (HON)
• Industrial Process Refrigeration Leak Repair
• U.S. Department of Transportation's (DOT) Pipeline Rules
• Occupational Safety and Health Administration's Respiratory Protection Standard
Weekly compliance alerts on final agency actions and a quarterly calendar of
compliance deadlines also are available through a subscription service called the
Regulatory Monitoring Service. Other services include a monthly poster series and
periodic workshops.
More information is available from CMA's Web site at:
COMPLIANCE
ASSISTANCE
TOOLS
46
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EPA and industry may consider focusing future root cause analyses on:
• Understanding why violations occur at facilities with EMSs.
• Looking more carefully at the "human error" category of causes,
as defined in this report, to distinguish between the causes within
the human error category and other causes that may better
address why the noncompliance occurred.
• Involving, at the design stage of the analyses, a statistician and social
psychologist to address group factors, norms, and cultures in the analyses.
• Studying noncompliance at small (less than 100 employees) companies
to better provide compliance assistance to small companies.
• Conducting more research through focus groups, or on a disclosed basis,
so that EPA and industry can more fully understand the relationship
between particular violations and appropriate corrective actions.
Streamline Regulations and Create Compliance Assistance Tools
Respondents frequently identified lack of facility awareness of regulation
applicability and inconsistent, contradictory, or ambiguous federal and state
regulations as root causes. The frequent identification of these causes, all
categorized as regulations and permits, was echoed by respondents'
recommendations about regulatory changes that would improve
compliance (see Chapter 4). Those recommendations were based on
respondents' experiences trying to comply with federal and state
requirements. This finding suggests two things. First, that new
regulations should be articulated more clearly and that federal and state
agencies should interpret regulations consistently. Second, federal and
state agencies should continue developing easily understood assistance
tools that will help the regulated community. As discussed in Chapter 4,
a compliance assistance idea and policy change respondents frequently
identified was the need for technical assistance in complying with new
and existing regulations, as well as publication of these tools with every
new rule. Specific compliance assistance tools suggested by respondents
include guidance and self-assessment documents, logic guides,
applicability notices, and seminars and workshops.
EPA can enhance outreach activities related to the applicability of new
regulations, in concert with industry and trade associations. Suggestions for
improving compliance and environmental performance activities include:
• Continue developing standard federal and state interpretations
of regulations.
• Continue developing plain-language guides.4
• Continue developing compliance assistance tools in cooperation
with trade associations.
• Continue working with industry in developing new regulations
and in improving existing regulations.
On June 1, 1 998, President Clinton signeda memorandum directing all federal agencies to writeregulationsandotherpublic communications
inplain language. In responseto this memorandum, EPA will writeallproposedandfinal rules inplain language. Existingrules will be
rewritteninplainlangiiageasEPAhas''theopportunityandresourcestodoso."
EPA should articulate new
regulations more clearly.
EPA should continue
compliance assistance and
outreach activities.
_
' •''
47
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• Improve notifications and outreach through Internet mailing lists or other
communication channels to inform industry about the available
compliance assistance tools.
Statute-Specific Recommendations
The project team identified patterns of noncompliance under specific statutes
and, in some cases, under several statutes. The table below identifies categories
of noncompliance associated with the statute(s) and ways in which industry
and EPA might help improve compliance and environmental performance.
Many of the following recommendations can be integrated into an EMS to
address the noncompliance categories identified. (Appendix F presents
recommendations related to specific statutes provided by respondents, but not
necessarily related to their noncompliance events.)
Statute
CAA
Frequently
Identified
Noncompliance
Categories
Operations and
Maintenance
Monitoring/
Detection/
Control
Record Keeping
Report
Submissions and
Reporting
Ideas for Improving Compliance
Develop technical guides for operation and
maintenance of equipment and training for operation
of equipment and update them regularly.
Work with vendors to operate new equipment
properly at startup.
Designate facility staff who routinely review and
assess the applicability of all new rules.
Provide training for employees and contractors in
meeting record-keeping requirements.
Develop written procedures for record keeping and
submittal of reports and update them regularly.
Develop plain-language electronic guidance and
compliance tools for meeting reporting requirements.
Such tools could include on-line decision trees (the
user enters process, units, and chemicals used) to
guide users through determination of the
applicability of regulations and their associated
compliance deadlines and reporting requirements.
The guidance would assist the user in completing
the applicable reporting form(s) electronically once
the decision tree has been completed.1
Develop tools to better explain the applicability of
rules and identify upcoming compliance dates
(reminders of compliance deadlines).
Lead
Responsibility
Industry
Industry
Industry
Industry
Industry
EPA and/or CMA
EPA
OSHA has developed several interactive expert systems that could be used as models for such tools.
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Statute
CWA
Frequently
Identified
Noncompliance
Categories
Exceed a nee
Ideas for Improving Compliance
Develop new or modify existing procedures for the
operation and maintenance and testing of new or
modified equipment and update those procedures
regularly.
Train employees and contractors in how to
implement new or modified procedures.
Implement procedures that direct managers to spot-
check operators' implementation of procedures.
Conduct periodic testing of equipment to evaluate
the remaining lifetime of equipment and to maintain
its proper functioning and performance (ensure that
permit limits are being met). When issues related
to permit limits arise, determine the appropriate
limit and work with the regulatory agency to
establish permit modifications.
Train employees and contractors on reporting and
notification requirements.
Develop training and written procedures for
meeting record-keeping requirements.
Improve procedures for use of contractors and
purchase of materials, equipment, and other
services.
Develop a computerized alert or "tickler" system for
reporting and notification.
Develop self-audit check lists or plain-language
guidance for all requirements that govern categorical
dischargers, including those for permitting, limits on
effluents, and those governing application of best
control technology (BCT) and best available
technology (BAT) for wastewater treatment.
Lead
Responsibility
Industry
Industry
Industry
Industry
Industry
Industry
Industry
EPA and/or CMA
EPA and/or CMA
49
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Statute
RCRA
EPCRA
TSCA
CERCLA
Frequently
Identified
Noncompliance
Categories
Waste
Identification
Record Keeping
Testing
Unpermitted/
Unauthorized
Activity
Report
Submissions and
Reporting
Ideas for Improving Compliance
Provide training for employees and contractors in
management of underground storage tanks (LIST) and
aboveground storage tanks (AST).
Improve procedures for use and purchase of
materials, equipment, and services.
Provide training for employees and contractors in
meeting record-keeping requirements.
Develop plain-language electronic guidance and
compliance tools for meeting reporting requirements.
Such tools could include on-line decision trees (the
user enters waste-type or facility specific information)
to guide users through determination of the
applicability of regulations and their associated
compliance deadlines and reporting requirements.
The guidance would assist the user in completing the
applicable reporting form(s) electronically once the
decision tree has been completed.
Develop self-audit check lists for management of
ASTs and USTs under 40 CFR 280, 265, and
264 subpart J.
Provide written procedures and training for
emergency reporting and notification requirements
and update the procedures regularly.
Develop plain-language electronic guidance and
compliance tools for meeting reporting requirements.
Such tools could include on-line decision trees (the
user enters chemical and facility specific information)
to guide users through determination of the
applicability of regulations and their associated
compliance deadlines and reporting requirements.
The guidance would assist the user in completing the
applicable reporting form(s) electronically once the
decision tree has been completed.
Lead
Responsibility
Industry
Industry
Industry
EPA and/or CMA
EPA and/or CMA
Industry
EPA and/or CMA
50
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Promote and Improve Self-Audit Incentives for Sustained
Compliance
The option to conduct self-audits and report the results to EPA and
state agencies may be a powerful incentive for facilities to demonstrate
sustained compliance. Respondents expressed considerable interest in
self-audits, both as an alternative to traditional compliance inspections
and as a "reward" for sustained compliance. Some respondents'
primary concern related to self-audits is whether penalties will be
imposed for self-reported deficiencies.
EPA should provide more
incentives for industry
to disclose violations.
EPA continues to explore
programs for recognizing
companies or facilities
that have strong histories
of compliance.
Self-Reporting Incentives
OECA's Audit Policy
EPA addresses industry self-audits and disclosure in its policy statement Incentives
for Self-Policing: Discovery, Disclosure, Correction and Prevention of Violations (60
F.R. 66705-66712, December 22, 1995). The policy reduces or, in some cases,
eliminates penalties for companies that voluntarily discover, promptly disclose, and
expeditiously correct violations. Under EPA's audit policy, through March 1998,274
companies had submitted audit policy disclosures for more than 966 facilities. The
gravity-based penalty was mitigated for disclosures submitted by 105 companies for
452 facilities. Action on disclosures submitted by 116 companies for 451 facilities
currently is unresolved. EPA encourages facilities to self-audit and disclose
findings. EPA also continues to evaluate the effectiveness of its audit policy.
More information about the audit policy is available at:
Small Business Policy
EPA's Small Business Policy was developed to help small businesses that have 100
or fewer employees achieve environmental compliance by creating benefits for
businesses that make a good faith effort to comply with environmental regulations
before a government agency discovers a violation or otherwise takes an enforcement
action.
The policy provides incentives, such as waivers or reductions of penalties, for
businesses that participate in on-site compliance assistance programs or conduct
environmental audits to discover, disclose, and correct violations.
More information about the small business policy is available at:
51
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APPENDIX A
RESPONSES TO SURVEY QUESTIONS
AND DATA LIMITATIONS
-------
RESPONSES TO SURVEY QUESTIONS AND _
DATA LIMITATIONS
This appendix is made up of five sections, corresponding to the following
sections of the Root Cause Analysis Pilot Project survey:
Section I - Demographic Information
Section II - Underlying and Contributing Causes
Section III - Response to the Noncompliance
Section IV - Environmental Management System Elements
Section V - Compliance and Enforcement Activities
Each question in the survey is reproduced here, and the number of responses
received is presented below the appropriate question. When necessary, the type
of response also is characterized (for example, the number of multiple answers
provided by a single respondent). In total, 27 surveys were completed and
returned.
In any survey, there are potential errors due to sampling and errors due to
nonresponse. Since the study design used here is a census, there is no
sampling error associated with the results. Since 23 of the 50 facilities in the
study population did not respond, the potential for nonresponse error is large,
especially so because, as noted above, the respondent facilities are clearly not
representative of all 50. Let us illustrate these concepts with an example. Of
the 69 noncompliance events in the sample, 7 (10%), were classified as
exceedance, all of which involved discharge limits under the Clean Water Act.
But there is no way of knowing what percentage of noncompliance events
among the nonrespondents would be classified as exceedances, or under
what statute they would be identified: it could be 0%, 10%, 50%, or any other
percentage. Thus, one cannot say that 10% of noncompliance events in the
whole study population are classified as exceedance, nor can one specify a
meaningful range (confidence interval) for the percentage of exceedance
noncompliance events in the study population.
Of the sixteen facilities with SIC code 2869 in the study population, fourteen
were large (100 or more employees) and thirteen of these responded. Since this
is essentially full response, the results of analysis for these facilities are
representative for this study group. However, all of these facilities are in EPA
Regions 2 and 6, so without further studies, one cannot conclude that these
results extend beyond the study population.
Completed surveys were received in two forms: electronic and paper. All the
paper surveys were converted to electronic format, so that the data could be
analyzed. The electronic format of the survey limited respondents (in the case
of certain questions) to specific responses; while the paper survey did not limit
respondents. Therefore, when some paper surveys were transcribed into the
electronic format, they were altered slightly. The intent of the respondent was
retained as much as possible during that process.
For example, in Section III, question 4 asked whether the facility had made an
inventory of past, current, or potential environmental impacts associated with
its operations, services, and products. The respondent was asked to check either
Yes or No, and, if Yes, to identify which (past, current, or potential) inventory
they had conducted. The electronic survey allowed the respondent only to
specify one type of inventory, while the paper version allowed the respondent to
specify as many as three.
To reduce the burden on respondents, noncompliance categories were created
to allow respondents to consolidate similar noncompliance events and
answer questions about the types, rather than specific noncompliance events.
This approach did not allow the direct correlation of responses to different
portions of the survey. Specifically, responses to Section IV (changes in EMSs)
could not be linked to responses to sections II and III (root and contributing
causes of noncompliance and actions taken).
A-2
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SURVEY FOR THE
ROOT CAUSE ANALYSIS PILOT PROJECT
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
AND THE
CHEMICAL MANUFACTURERS ASSOCIATION
A-3
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Section I
1. Please provide the remaining numbers of the primary four-digit SIC code of the facility.
All 27 respondents answered. One respondent provided two primary SIC codes, and another
respondent listed a primary SIC code outside the 28 group.
2. How many employees were located at the facility at the time of the noncompliance?
(Please check one box each for A and B.)
A. Full-time employees
D 0-9 D 10-49 D 50-100 D 101-500 D More than 500
B. Full-time contractors
D 0-9 D 10-49 D 50-100 D 101-500 D More than 500
All 27 respondents answered both parts of this question.
3. What are the job responsibilities of the person(s) completing this survey?
(Check all that apply.)
n Compliance Staff fj Operator fj Environmental Engineer
n Corporate Management FJ Plant Management FJ Engineer (non-environmental)
n Other (specify)
All 27 respondents answered this question. The number of responses per survey varied; 14 surveys
listed only 1 job responsibility, 8 surveys listed 2 job responsibilities, 3 surveys listed 3 job
responsibilities, and 2 surveys listed 4 job responsibilities.
4. Identify the activities currently performed at the facility (for example, production, packaging, storage, and
research and development).
All 27 respondents answered this question.
5. How many years has the facility been in operation (as of today)?
D 1-5 D 6-10 D More than 10
All 27 respondents answered this question.
A-4
-------
Section I
6. Use a check (/) in the correct column to indicate how long each EMS or policy has been in place at your facility.
Of those checked, rank each based on the influence they have had on your overall environmental performance
(1 = greatest, 8 = least).
Environmental Management System
Responsible Care® Management Systems (check all that apply)
Policy and Leadership
Planning
Implementation, Operation, and Accountability
Performance Measurement and Corrective Action
Management Review and Reporting
Length of Time in Place (3)
Less than 1-5
1 year years
More than
5 years
25
24
25
25
25
Rank
23
22
23
23
23
Corporate Policies, Goals, Targets, or Guidelines — for example, corporate audits (describe)
Description
26
24
Other EMSs — for example, ISO1 4001, GEMI (describe)
Description
7
7
Environmental Audit Program (describe)
Description
23
22
The number in each column indicates the number of respondents who indicated that element.
A-5
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Section II
List the two-character noncompliance code(s) identified for your facility. List all that apply.
All 27 surveys identified noncompliance codes. The number of noncompliance codes per survey
varied:
10 surveys identified only 1 noncompliance code
7 surveys identified 2 noncompliance codes
4 surveys identified 3 noncompliance codes
3 surveys identified 4 noncompliance codes
2 surveys identified 6 noncompliance codes
1 survey identified 9 noncompliance codes
for a total of 69 noncompliance codes
Categories And Items
Underlying Cause
Contributing Cause
Human Error
Policies
Procedures
Management
Training
Communications — Difficulties Between
Emergency Preparedness
Process Upset or Failure as a result of Compliance Monitoring
Regulations and Permits
External Circumstances
Equipment Problems
Other Categories or Items (specify)
97 underlying, or root
causes were identified by
respondents.
127contributing causes
were identified by
respondents.
A complete listing of specific items is included in Appendix C.
Complete the following ONLY if you identified equipment problems as a cause.
Check (^) the appropriate box in the left column to indicate the type of equipmnet involved and then
draw a line to the item(s) in the right column that indicates the function(s) that was lost.
Type of Equipment:
Q Piping •
Q Tanks, vessels, reactors •
Q Pumps, compressors, blowers, turbines (rotating
equipment) •
Q Motors •
Q Heat exchangers •
Q Control valves
Q Solids handling •
Q Instrumentation •
Q Other (specify) •
Equipment function that was lost:
Containment
Process control
Active mitigation
Passive mitigation
Material transport
Other (specify)
All 9 respondents who identified equipment problems as a cause responded to the equipment
problems question above.
A-6
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Section III
1. For each action taken, complete all columns.
List all actions the facility took to
prevent recurrence of the
noncompliance, including
development or enhancements of
EMSs.
List the
associated
two-character
noncompliance
codes.
Was the
action
taken?
(Check
one)
ST
LT
How did the facility verify that the
action taken would ensure
compliance? (For example, was
the action verified through a self-
assessment audit, root cause
analysis, or EMS audit?)
Describe any lessons learned and
with whom the facility shared
those lessons—for example, sister
facilities or trade associations.
a.
127
62
125
117
70
26 respondents completed to this section; the 1 who that did not respond stated that the question was not applicable to the noncompliance
in question, because the noncompliance occurred during closure, after all manufacturing operations had ceased. Respondents described
a total of 127 actions for 62 of the 69 noncompliance codes identified in Section II. The number in each column indicates the number of
responses to that element.
-------
Section III
2. Which facility life cycle step(s) was the focus of re-engineering to reduce or eliminate the possibility of similar
future incidents of noncompliance? Check the appropriate box in the left column to indicate the life cycle step
and then draw a line to the item(s) in the right column that indicate the aspect(s) of the EMS that was (were)
modified to avoid similar incidents.
Life Cycle Steps
Research and Development ..................
Design
Process Hazards Analysis
Fabrication
Emergency Planning and Response
Pre-Startup Review
Startup
Operation
Inspection and Testing
Maintenance
Other (specify)
Aspects of the EMS
Operational Discipline
• Procedures
• Training
• Demonstration of Performance
• Documentation
• Other (specify)
Checks and Balances
• Quality Assurance/Quality Control
• Handling of Deviations
• Mangement of Change
• Other (specify)
Feedback
Incident Reports
Audits
Performance Data (people, chemical process, or
equipment)
Other (specify)
22 respondents answered this question.
3. Would Responsible Care® or another EMS—if implemented before the occurrence of the noncompliance—
have contributed to prevention of the incident?
n YES n NO Please comment on your answer.
26 respondents answered this question; 23 of the 26 provided comments.
4. Has the facility made an inventory of past, current, or potential environmental impacts associated with its
operations, services, and products?
DNO DYES If YES, which? DPast
n Current
D Potential
If yes, how has an inventory of environmental impacts affected the facility's ability to manage compliance
with environmental regulations?
22 respondents answered this question; all those who responded YES provided comments.
A-8
-------
Section IV
To complete this section:
If more than one facility case-specific profile was provided, complete this section based on the status of your EMS at the time
of the most recent enforcement action, as indicated by the "Commenced Date" on the facility case-specific profiles.
COLUMN
A Was the element part of the facility's EMS at the time of the noncompliance? Check the appropriate YES or NO column for each element.
B Is the element currently part of the facility's EMS? Check the appropriate YES or NO column for each element.
C Does the facility consider the element part of Responsible Care® or another EMS to which the facility subscribes? Check the appropriate column for each
element and indicate whether the element has been clarified (C), added (A), or not changed (NC) to prevent recurrence of the noncompliance.
26 respondents completed this section; the 1 who did not respond stated that the question was not applicable to the noncompliance in question,
because the noncompliance occurred during closure, after all manufacturing operations had ceased. The number in each row indicates the number
of responses to that element.
A. Part of the facility's
EMS at the time of the
noncompliance?
YES
NO
B. Presently part
of the facility's
EMS?
YES
NO
C. Element is part of ...
n i i r r^ r /\
Kesponsible Lare® (y )
Another EMS
. /N
(y )
To prevent recurrence of the noncompliance,
this element was...
C = Clarified A=Added NC = Not Changed
1 . Policy and Leadership
A. The facility's goals and objectives statement includes an environmental
policy statement.
24
22
B . Top management defines environmental policy and sets goals and
expectations regarding environmental performance.
26
24
C. The philosophy of continuous improvement is integrated into the
environmental policy.
24
22
D. The environmental policy contains an explicit written commitment to
regulatory compliance and pollution prevention.
25
23
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Section IV
2. Planning
A. Environmental planning is part of the budget and business development
process.
B . The planning process includes setting specific objectives and targets
with time frames.
3. Implementation, Operation, and Accountability
A. Formal lines of authority and responsibility and accountability for
environmental management have been established.
B . Environmental managers have organizational stature, independence, and
authority to implement environmental programs and to make decisions
relating to environmental protection.
C. Responsibility for environmental management is incorporated into
personnel evaluations, rewards, and incentives.
D. There is a system in place to review and update environmental
procedures periodically.
E. There is a system in place for tracking and interpreting new and/or
changes to Federal, state, and local regulations and updating facility
policies and directives for the organization's response.
F. Responsibility and accountability for environmental performance are
shared between staff employees and managers at all levels.
A. Part of the facility's B. Presently part
EMS at the time of the of the facility's
noncompliance? EMS?
YES NO YES NO
(/) (/) (/) (/)
24
24
25
26
23
26
26
24
C. Element is part of ...
D -i i r /» / /\ Another EMS
Kesponsible Lare® (•/ ) . ..
To prevent recurrence of the noncompliance,
this element was...
C=Clarified A=Added NC = Not Changed
22
22
23
23
21
24
24
22
-------
Section IV
3. Implementation, Operation, and Accountability (continued)
G . Staff are encouraged to communicate environmental issues and concerns
directly with top management and/or environmental managers.
H. There is a system in place to ensure that personnel with environmental
responsibilities have the relevant background and training to carry out
their responsibilities.
1 . There is a system in place to ensure that environmental reports required
by Federal and state regulations are prepared routinely and submitted
on a timely basis.
J . Procedures are established to identify the potential for and response to
emergency situations.
4. Performance Measurement and Corrective Action
A. The facility has developed and implemented a preventive maintenance
program to ensure proper operation of pollution control equipment.
B . Environmental compliance audits are conducted at least every three
years.
C. Audits are conducted by persons independent of the facility unit which
is the subject of the compliance audit.
D. Compliance audit results are reported directly to facility management.
A. Part of the facility's B. Presently part
EMS at the time of the of the facility's
noncompliance? EMS?
YES NO YES NO
(/) (/) (/) (/)
26
26
26
26
24
25
23
26
C. Element is part of ...
D -i i r /» / /\ Another EMS
Kesponsible Lare® (/; ....
(y)
To prevent recurrence of the noncompliance,
this element was...
C=Clarified A=Added NC = Not Changed
24
24
23
24
22
23
22
23
-------
Section IV
A. Part of the facility's
EMS at the time of the
noncompliance?
YES
NO
B. Presently part
of the facility's
EMS?
YES
NO
C. Element is part of ...
Responsible
Another EMS
To prevent recurrence of the noncompliance,
this element was...
C = Clarified A=Added NC = Not Changed
4. Performance Measurement and Corrective Action (continued)
E. A formal system is in place for follow-up of exceptions noted in
inspections or audits and supported by management review.
24
22
F. Periodic environmental management system audits are conducted at the
facility.
22
20
G. The integrity and efficacy of the EMS are periodically reviewed and
revisions are made based on the results of this review.
16
16
H. The facility has developed a written description of the facility EMS
that describes its organizational and functional structure and elements.
19
18
I. The facility has designated a point-of-contact for records relating to the
EMS.
21
20
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Section V
1. When an underlying cause(s) or contributing cause(s) was identified under Regulations and Permits in Section
II, identify the specific regulatory provision or language pertinent to the noncompliance and the associated two-
character noncompliance code. Please identify compliance assistance tools or regulatory reforms that would
help your facility comply with the regulatory provision or language.
Regulatory Provision or Language
35
Compliance Assistance Tools or Regulatory
Reforms
29
41 responses to this question were expected (because regulations and permits was identified as a
root or contributing cause 41 times, by 20 respondents, in Section II). 35 of those responses were
addressed by 19 respondents. However, several respondents identified more than one compliance
assistance tool or regulatory reform for a noncompliance code:
1 respondent provided 3 responses for 1 noncompliance code
1 respondent provided 2 responses for 1 noncompliance code
24 respondents provided 1 response for 1 noncompliance code
In some cases, respondents indicated the same noncompliance code more than once under
Regulations and Permits in Section II:
3 respondents indicated the same noncompliance code 2 times
1 respondent indicated the same noncompliance code 3 times
1 respondent indicated the same noncompliance code 5 times
In each case listed above, the respondent provided 1 response to this question.
The number in each box indicates the number of responses to that element.
A-13
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Section V
2. List three other regulations for which compliance assistance could improve facility compliance. Identify the
three regulations (not identified in your facility case-specific documents) and the noncompliance categories
with which compliance is most difficult. Identify compliance assistance tools or regulatory reforms that
would help your facility comply with the regulatory provision or language.
Regulatory Provision or Language
Compliance Assistance Tools or
Regulatory Reforms
22
22
11 respondents answered this question.
5 respondents provided 3 responses; 3 of those respondents specified 3 noncompliance
codes, 1 of those respondents specified 2 noncompliance codes and did NOT specify a
noncompliance code for one answer, and 1 of those respondents did NOT specify a
noncompliance code for any answer
1 respondent provided 1 response; the respondent specified 1 noncompliance code and
did NOT specify a noncompliance code for one answer
5 respondents provided 1 response and specified 1 noncompliance code
3. Describe any other regulatory reform initiatives or opportunities that would enable the facility to comply more
efficiently with environmental requirements.
14 respondents answered this question.
4. What industry evaluation methods (for example, compliance audits or EMS audits) could be used as
substitutes for traditional compliance inspection, and how could facilities or government demonstrate the
credibility of such evaluation methods to the public?
16 respondents answered this question.
5. What incentives could EPA use to acknowledge or reward sustained compliance?
21 respondents answered this question.
A-14
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Section V
6. If a government compliance inspector provided compliance assistance, was that assistance effective?
DYES QNO
If YES, what did the inspector do and how was that assistance useful?
If NO, how can EPA improve its efforts to provide such assistance?
27 respondents answered this question; 15 of the 27 provided comments.
7. For the concluded action(s) summarized in the facility case-specific profile(s), could Supplemental
Environmental Projects have been incorporated to provide more environmentally beneficial settlements? If so,
please provide specific examples.
17 respondents answered this question.
A-15
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Section V
8. Check the appropriate YES or NO column to indicate the compliance assistance sources the facility has used.
Indicate how useful you found each source by circling the appropriate number. If you did not use a source,
indicate how useful you think it would be.
YES
(/)
NO
(/)
Compliance Assistance Sources
Agency hotlines
Conferences
Consultants
Federal employees
State employees
Your facility's employees
Internet
Other facilities
Federal publications
State publications
State compliance assistance organizations
Tools developed by the facility
Trade associations
Universities
Vendors and suppliers
Other (specify)
Not Very Useful Very Useful
23
26
26
25
26
25
23
26
25
24
29
24
25
20
22
4
26 respondents answered this question; the 1 who did not respond stated that the facility was closed
and that the question was not applicable. The number of responses concerning the usefulness of each
item varied; the number in each row indicates the number of responses to that element.
A-16
-------
Section V
9. Does your facility participate in any state or Federal voluntary programs?
DYES QNO
If YES, please identify the program(s) and explain its effect on compliance.
If NO, please explain why.
27 respondents answered this question; 25 of the 27 provided comments.
10. On a scale of 1 to 10 (with 10 being the most assistance), rate each of the following areas for its helpfulness to
your facility in improving compliance.
25 More clearly defined management commitment
23 Increased number of employees
26 Increased employee involvement
26 Increased facility management involvement
25 Improved access to EPA technical experts
25 Improved corporate/facility communication
24 Improved facility management system
25 Improved intra-facility communication
26 Improved record-keeping procedures
26 Improved tracking system
26 Improved understanding of the regulations
26 More clearly defined responsibilities
24 More modern equipment
0 Other (specify)
26 respondents answered this question; the 1 who did not respond stated that the facility was
closed and that the question was not applicable. The number in each row indicates the number
of responses to that element.
A-17
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APPENDIX B
DEFINITIONS OF NONCOMPLIANCE CATEGORIES
-------
DEFINITIONS OF NONCOMPLIANCE CATEGORIES
Corrective Action Activities
Although not necessarily a noncompliance with the regulations, this category
addresses corrective action activities imposed by a legal agreement such as a
§ 3008(h) or § 3013 order.
Equipment/Unit Design
Noncompliance resulting from design deficiencies for structures, systems, or
resources.
Exceedance
Failure to meet discharge limit(s) as defined in the facility permit or by
regulation.
Failure to Respond
Failure to respond to an information request.
Labeling
General noncompliance with regulations requiring labeling and placarding.
Legal Agreement
Failure to correct a noncompliance in accordance with any agreement or to
achieve a milestone per any agreement requirements.
Monitoring/Detection/Control
Failure to comply with monitoring, detection, or control requirements.
Operations and Maintenance
General noncompliance of an operational and maintenance nature such as: the
use of defective containers; failure to close hazardous waste containers; lack of
aisle space in storage areas; or failure to perform required equipment
inspections, calibrations, and maintenance.
Record Keeping (incomplete or late)
Noncompliance concerning operating records or files, not maintained in
accordance with regulations. This includes failure to maintain training records
as required by regulation, and failure to file complete/accurate manifest
reports.
Report Submissions and Reporting
General failures to submit required reports, or the submittal of incomplete/
inaccurate reports, to the regulating agencies. Includes the failure to report
spills or releases to the regulating agencies in a timely manner as defined by
regulation.
B-2
-------
Spills/Releases
Noncompliance relating to spills or releases.
Testing
Failure to perform sampling or analysis in accordance with prescribed
procedures or permit criteria.
Training/Certification
Failure to train environmental personnel in the performance of their duties as
specified by regulation (includes inadequate training, failure to conduct
refresher training). This includes lack of training/certification records and
failure to have certification training.
Unpermitted/Unauthorized Activity
Noncompliance resulting from unpermitted or unauthorized activities or
equipment. Includes noncompliance with permit requirements and failure to
obtain a permit/authorization.
Waste Identification
Failure to identify/characterize waste as required by regulation.
B-3
-------
APPENDIX C
ROOT AND CONTRIBUTING CAUSE
CATEGORIES AND SPECIFIC CAUSES
-------
ROOT AND CONTRIBUTING CAUSE
CATEGORIES AND SPECIFIC CAUSES
Human Error
1. Individual responsibility or professional judgment
2. Fatigue, lack of alertness, distraction
3. Inexperience, lack of knowledge, lack of technical expertise
4. Other (specify)
Policies
5. Unavailable policy
6. Unclear policy
7. Environmental objectives and targets unclear
8. Policy not followed
9. Pollution control technologies or other technical equipment needs not assessed
10. Other (specify)
Procedures
11. Operating procedure not followed
12. Operating procedure unclear or out of date
13. Difficult to relate operating procedures to actual facility operations and products
14. No written operating procedures available
15. Record keeping procedures inadequate
16. Definition of roles and responsibilities unclear
17. Reporting or notification procedures unclear
18. Pre-startup review not conducted or inadequate
19. Other (specify)
Management
20. No formal management structure to address noncompliance and follow-through
21. Management organization undefined
22. Management support or guidance not provided
23. Staffing — inappropriate level or expertise
24. Environmental aspects of facility process and operations not identified
25. Control and oversight of purchased materials, equipment, and services not provided or inadequate
26. Environmental planning or budgeting not completed
27. Result of economic competition
28. Other (specify)
C-2
-------
Training
29. Employee not trained
30. Training materials unclear or outdated
31. Training not available
32. Training requirements unclear
33. Other (specify)
Communications — difficulties between
34. Employees
35. Management and employee
36. Facility and regulatory agencies
37. Other (specify)
Emergency Preparedness
38. Emergency Preparedness Plan unavailable
39. Emergency Preparedness Plan insufficient
40. Emergency Preparedness Plan implementation issues
41. Other (specify)
Process Upset or Failure as a result of
42. Over pressure
43. Over temperature
44. Runaway reaction
45. Raw material
46. Other (specify)
Compliance Monitoring
47. Audit program insufficient
48. Audit follow-up procedures insufficient
49. Routine site and equipment compliance checks not conducted
50. No system to ensure timely submission of environmental reports to regulatory agency
51. Insufficient environmental data
52. Other (specify)
C-3
-------
Regulations and Permits
53. Conflicting permit conditions
54. Ambiguous Federal regulations
55. Ambiguous state regulations
56. Regulatory change not communicated by regulatory agency
57. Contradiction between state and Federal regulations
58. Inconsistent or contradictory Federal regulations
59. Inconsistent or contradictory state regulations
60. Inconsistent or contradictory interpretation of Federal regulations
61. Inconsistent or contradictory interpretation of state regulations
62. Facility unaware of applicability of a regulation
63. Rule implementation time frames are too short
64. Other (specify)
External Circumstances
65. An act outside the control of the individuals who operate the process
66. External phenomenon (for example, weather, theft, flood, fire)
67. Contracted services such as haulers or handlers
68. Other (specify)
Equipment Problems
69. Design or installation
70. Equipment maintenance
71. Ordinary wear-and-tear
72. Site and equipment inspections not conducted
73. Exceptions noted in inspections were not followed up
74. Other (specify)
Other Categories or Items (specify)
75.
76.
77.
C-4
-------
APPENDIX D
STATUTES
-------
STATUTES
This appendix presents survey findings related to specific statutes. The
relationships among individual statutes and noncompliance categories and
the root and contributing causes are discussed below. In addition, the
actions taken to address noncompliance events as they are related to each
statute are discussed.
Noncompliance Events and Statutes
Most (72%) noncompliance events occurred under the Clean Water Act (CWA),
the Resource Conservation and Recovery Act (RCRA), and the Clean Air Act
(CAA). For each statute, the type of noncompliance events most frequently
identified for each statute was:
• CWA - Exceedance
• RCRA - Unpermitted/unauthorized activity
• CAA - Operations and maintenance
• Toxic Substances Control Act (TSCA), the Comprehensive Environmental
Response, Compensation, and Liability Act (CERCLA), and the
Emergency Planning and Community Right-to-Know Act (EPCRA) -
Report submissions and reporting
Most noncompliance events were associated with the CWA and RCRA;
specifically, the CWA and RCRA were associated with 29% and 23%,
respectively, of all types of noncompliance events.
Causes and Statutes
For each statute, the cause of a noncompliance event most frequently
identified, characterized as a root or a contributing cause, was:
• CWA - Regulations and permits and procedures, each identified with the
same frequency
• RCRA and CERCLA - Human error
• CAA and EPCRA - Regulations and permits
• TSCA - Management
Actions Taken
For each environmental statute, actions taken in response to noncompliance
events were reviewed. (Respondents had described the actions taken by the
facility in response to noncompliance events.) For all statutes except the CWA,
most actions taken in response to noncompliance events were management or
administrative in nature—that is, they pertained to policy, procedures, reporting,
or training. In contrast, most actions taken in response to noncompliance events
under the CWA were technical—for example, upgrades of treatment systems,
modification or installation of equipment, or source reduction.
The following sections present the noncompliance events, root and
contributing causes, and actions taken in response to noncompliance events for
each statute. For each statute, two figures are presented. The first figure
presents the noncompliance categories most frequently identified for the
statute. The second figure presents the root and contributing causes most
frequently identified.
D-2.
-------
Clean Water Act
The largest number of noncompliance events for the CWA involved
exceedances and events related to requirements for report submissions and
reporting.
Respondents identified the root and contributing causes of each
noncompliance event. Under the CWA, the root causes most frequently
identified were equipment problems, external circumstances, and human error.
Specific causes associated with the root causes included:
• Equipment problems: design or installation, equipment maintenance, ordinary
wear-and-tear, and premature failure of equipment operating within its design life
• External circumstances: external phenomenon (for example, weather or fire),
contracted services, and site-wide power failure
• Human error: individual responsibility or professional judgment and
inexperience, lack of knowledge, lack of technical expertise
The contributing causes most frequently identified were procedures and
regulations and permits.
In contrast to all other statutes, most actions taken in response to noncompliance
events under the CWA were technical in nature, and many of those actions were
related to storm-water issues. Specific examples include: improvement of
sewer integrity, source reduction of pollutants discharged to wastewater
treatment, expansion or upgrades of wastewater treatment systems, design
standards, installation of equipment, and changes in equipment design. Two
facilities that had had CWA noncompliance events related to reporting
instituted procedures involving outside laboratories: one established
requirements that the laboratory provide early test results by facsimile and
telephone for any results exceeding permit conditions; the other required that
the laboratory perform monitoring.
Management or administrative actions associated with technical actions
addressed training of employees, analytical testing procedures, and
monitoring procedures.
More than in the case of any other statute, noncompliance events under the
CWA were associated with exceedances and reporting. This finding is
consistent with the nature of regulations under the CWA, which focus on end-
of-pipe discharge limits and reporting mechanisms for verifying that
discharge limits are met. While most root causes identified for noncompliance
events associated with the CWA were either technical (equipment problems) or
accidental (human error and external circumstances), the procedures and
regulations and permits categories stood out as the primary contributing
causes. This finding is particularly noteworthy in light of actions taken in
response to noncompliance events. Most actions taken addressed technical
aspects of noncompliance (for example, equipment changes and operational
refinements); however, relatively few actions taken addressed contributing
causes that involved procedure failure or lack of understanding of
regulations. Such contributing causes could be corrected by implementation
of a formal environmental management system (EMS) that includes
preventive actions and training to improve compliance, as well as by
clarification of interpretation of regulations.
D-3.
-------
Noncompliance Type
Exceedance
Monitoring/
Detection/Control
Operations and
Maintenance
Record Keeping
Report Submissions
and Reporting
Waste Identification
CAA Noncompliance Events
type of noncoi ipliance was not identified by
2345
Number of Noncompliance Events
Noncompliance Type
Exceedance
Monitoring/
Detection/Control
Operations and
Maintenance
Record Keeping
Report Submissions
and Reporting I
Waste Identification
CERCLA Noncompliance Events
Thi-
type of nonconpliance was m
This
type of nonconpliance was net identified by
Thi«
This
ype of noncon
type of noncon
t identified by respondents under CERCLA.
'espondents un
ipliance was net identified by
ipliance was nc t identified by
Jer CERCLA,
espondents un<
Jer CERCLA.
espondents unJer CERCLA.
TTiis
type of noncon
ipliance was nc
t identified by
respondents un
Jer CERCLA.
2345
Number of Noncompliance Events
Noncompliance Type
Exceedance
Monitoring/
Detection/Control
Operations and
Maintenance
Record Keeping
Report Submissions
and Reporting
Waste Identification
CWA Noncompliance Events
type of nonconpliance was not identified by respondents ur
type of noncoi ipliance was not identified by respondents ur
2345
Number of Noncompliance Events
D-4
-------
Noncompliance Type
Exceedance
Monitoring/
Detection/Control
Operations and
Maintenance
Record Keeping
Report Submissions
and Reporting
Waste Identification
EPCRA Noncompliance Events
This type of noncom
Thist
ype of noncom
Thist
fiance was not identified by r spondents unc
aliance was not
ype of noncom
This Vpe of noncom ilia nee was not
iliance was nol
identified by rapondents uncer EPCRA
er EPCRA.
identified by r tspondents unc er EPCRA
identified by respondents under EPCRA.
Tliist
ype of noncom
iliance was not
identified by rrspondents uncer EPCRA.
23456
Number of Noncompliance Events
Noncompliance Type
Exceeda nee
Monitoring/
Detection/Control
Operations and
Maintenance
Record Keeping
Report Submissions
and Reporting
Waste Identification
RCRA Noncompliance Events
Noncompliance Type
Exceedance
Monitoring/
Detection/Control
Operations and
Maintenance
Record Keeping
Report Submissions
and Reporting
Waste Identification
TSCA Noncompliance Events
2345
Number of Noncompliance Events
D-5.
-------
Resource Conservation and Recovery Act
Most noncompliance events under RCRA involved waste identification and
record keeping.
The root causes most frequently identified were human error, procedures, and
regulations andpermits. Specific causes associated with the root causes included:
• Human error: individual responsibility or professional judgment
• Procedures: operating procedure not followed and management of change
inadequate
• Regulations andpermits: ambiguous federal regulations and inconsistent or
contradictory interpretation of federal regulations
Contributing causes included compliance monitoring, human error,
procedures, management, and regulations and permits.
Actions taken were primarily management or administrative in nature—that is,
they involved changes in waste management procedures and plans, audits and
startup reviews, training, and waste identification. One technical action that
involved removal of an underground pipeline was identified.
RCRA identifies solid and hazardous waste management practices that
generators of such wastes must follow. Consequently, noncompliance events
under RCRA primarily involved management practices and procedures, such
as waste identification unique to RCRA. Findings of the survey indicate that
there is a natural connection between noncompliance events under RCRA
and failure to implement required practices through human error and faulty
procedures. Those root causes likewise are related to one another, in that
human error can lead to failures of procedures and poor procedures can create
conditions under which human error is likely to occur. The complexity of
RCRA regulations likely contributed to the identification of regulations and
permits as the third most frequently occurring root cause category. Actions
taken in response to noncompliance events for the most part were consistent
with the root cause—that is, most actions focused on updating of plans and
procedures and training of staff.
Clean Air Act
Noncompliance events under the CAA were distributed almost equally among
operations and maintenance, monitoring/detection/control, record keeping,
and reporting.
The root causes most frequently identified were regulations andpermits, human
error, and procedures. Specific causes associated with the root causes included:
• Regulations and permits: facility unaware of applicability of the regulations
• Human error: individual responsibility or professional judgment; and
inexperience, lack of knowledge, lack of technical expertise
• Procedures: operating procedures not followed, record keeping procedures
inadequate, and no written operating procedures available
Contributing causes included compliance monitoring and regulations and
permits.
Almost all specific actions taken were administrative or management in
nature—that is, the actions involved audits, employee training, regulatory
D-6.
-------
changes, modifications of reporting and other procedures. A few actions were
technical in nature; they included:
• A performance test was conducted
• Distillation columns were brought into compliance.
One facility that had had a noncompliance event under the CAA took action by
working with CMA and EPA to modify the NESHAP regulations.
The most common root and contributing causes of noncompliance under the
CAA involved misinterpretation or lack of awareness of applicable regulations
and permit conditions. The frequency with which this cause was identified for
noncompliance events under the CAA, compared with the frequency of its
identification under other statutes, suggests that both EPA and industry
should consider efforts to clarify, communicate, and understand regulatory
obligations under the CAA.
Comprehensive Environmental Response, Compensation, and Liability Act
The noncompliance event identified most frequently under CERCLA involved
report submissions and reporting.
The root causes most frequently identified were human error and procedures.
Specific causes associated with the root causes included:
• Human error: individual responsibility or professional judgment and
inexperience, lack of knowledge, lack of technical expertise
• Procedures: operating procedures not followed and operating procedures unclear
or out of date
Contributing causes included human error, communications difficulties,
compliance monitoring, external circumstances, and equipment problems.
All actions taken in response to CERCLA violations were administrative or
management in nature, and most pertained to reporting procedures. Only one
technical action was identified—the elimination of underground pipelines
containing hazardous material.
Toxic Substances Control Act
Noncompliance events under TSCA were related to report submissions and
reporting, record keeping, and operations and maintenance.
The root causes most frequently identified included communication
difficulties and regulations and permits. Specific causes associated with the
root causes included:
• Communication difficulties: between employees, between facility and
regulatory agencies, and between customers
• Regulations and permits: facility unaware of applicability of a regulation
Contributing causes involved management and procedures.
Actions taken in response to noncompliance events under TSCA were
management or administrative in nature, for example:
• Reporting - sending notification of PCB activity
• Record keeping - documented all inspections performed
D-7.
-------
CAA Root and Contributing Causes
Human Error
Procedures
Management
-
-^^^1
Communications ^^I^H
(difficulties between) ^^^H
Compliance Monitoring
Regulations and Permits
i
External Circumstances ^^^^^H
_^^^H
Equipment Problems
1 1
•
D
Root Cause
Conti&utin
1 Cause
Cause Category
Human Error
Procedures
Management
Communications
(difficulties between)
Compliance Monitoring
Regulations and Permits
external (_ircu Distances
Equipment Problems
234567
Number of Times Identified as a Root/Contributing Cause
CERCLA Root and Con tri but ins Causes
10
2345678
Number of Times Identified as a Root/Contributing Cause
10
Cause Category
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(difficulties between)!
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n
Roof Com
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Number of Time! Identified as a Root/Contributing Cause
10
D-8.
-------
Cause Category
Human Error
Management
Communications
(difficulties between)
Compliance Monitoring
Regulations and Permits
External Circumstances
Equipment Problems
_
trs.
rwv i\o
ai ana <
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23456789
Number of Times Identified is i Root/Contributing Ciuse
10
Cause Category
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(difficulties between)
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I^^BIXS » i^wwi a MM wwnti iwMhing wau««>0
-
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2345678
Number of Times Identified as a Root/Contributing Cause
10
Cause Category
Human Error
Procedures
Management
Communications
(difficulties between)
Compliance Monitoring
Regulations and Permits
External Circumstances
Equipment Problems
TSCA Root and Contributins Causes
10
Number of Times Identified as a Root/Contributing Cause
D-9.
-------
• Employee training - providing training to relevant employees
• Sampling procedures - sampling all material for PCBs prior to storage so
that a PCB storage facility would not be required on site
One facility that had had a reporting noncompliance event under TSCA,
removed PCBs from the facility, so that it would no longer be required to report.
Most noncompliance events under TSCA involved administrative violations
(labeling, record keeping, and reporting) associated with management of
PCBs. Actions taken generally appeared consistent with the root causes
identified—that is, actions involved employee training and clarifications of
procedures. The frequency with which two contributing causes, management
and procedures were identified, raises questions about the efficacy of an EMS
at the facilities that had had TSCA violations. In fact, one respondent stated
that an "EMS program with a TSCA portion may have prevented" the
noncompliance event.
Emergency Planning and Community Right-to-Know Act
Report submissions and reporting was the sole type of noncompliance event
under EPCRA identified by respondents.
The root causes most frequently identified noncompliance events under
EPCRA include regulations and permits and compliance monitoring. Specific
causes associated with the root causes included:
• Regulations and permits: ambiguous federal regulations, and inconsistent or
contradictory interpretation of federal regulations
• Compliance monitoring: audit program insufficient
Contributing causes included human error and regulations and permits.
All actions taken involved reporting procedures. This finding is consistent with
the nature of EPCRA requirements, which are reporting and administrative
in nature.
Half the noncompliance events were attributed to ambiguous, inconsistent, or
contradictory federal regulations or interpretations of those regulations. That
finding suggests that there is great need for clarification of the EPCRA program.
The natures of root and contributing causes of noncompliance events under
EPCRA and of actions taken also suggest that ongoing training is necessary to
help employees better understand requirements of EPCRA, so that systems and
procedures can be developed to support the preparation of complete and
accurate EPCRA reports.
D-10.
-------
APPENDIX E
COMPARISON OF THREE EMS MODELS
-------
COMPARISON OF THREE EMS MODELS
This appendix provides a comparison of three environmental management
system (EMS) models. In the descriptions, references (in parenthesis) are
made to sections or criteria in each EMS model. A source from which one can
obtain more information or a copy of the EMS model document also is
provided.
E-2
-------
EMS Framework Comparison
Responsible Care®
ISO 14001
NEIC EMS Criteria
Developer
Chemical Manufacturers Association (CMA)
International Standards Organization (ISO)
EPA National Enforcement Investigations Center (NEIC)
Description
CMA member companies are required to commit
to (in writing) and implement the six codes of
management practices of Responsible Care®:
• Community Awareness and
Emergency Response
• Pollution Prevention
• Process Safety
• Distribution
• Employee Health and Safety
• Product Stewardship
The integration of these codes into a management
system is achieved in part through a Management
Systems Verification process, which is also part of
Responsible Care®.
CMA members are required to implement
Responsible Care® in a manner that
accommodates the facilities' operating practices.
The ISO EMS standard (1 4001) provides an
organized framework for an EMS that is based on
five components:
• Policy
• Planning
• Implementation and Operation
• Checking and Corrective Action
• Management Review
These components are deployed through 1 7 key
elements. The standard provides the overall
structure of the EMS; however, the content and
level of detail are left to the company
implementing the EMS. Philosophically, the
standard borrows many concepts from quality
management systems, including continuous
improvement through a "plan-do-check-act" cycle.
While it clearly emphasizes continuous
improvement, the standard does not define specific
levels of environmental performance.
Using the basic EMS structure, companies develop
the specific details, terms, and conditions for
developing and implementing an EMS.
Through numerous multimedia compliance investigations, EPA
(NEIC) observed that noncompliance most often was caused by
dysfunctional EMSs. Drawing on that experience, EPA developed
a EMS focused on compliance to identify pertinent environmental
requirements and translate them into sustainable compliance
activities. The compliance-based EMS contains the following 1 2
elements:
• Management Policies and Procedures
• Organization, Personnel, and Oversight of EMS
• Accountability and Responsibility
• Environmental Requirements
• Assessment, Prevention, and Control
• Environmental Incident and Noncompliance
Investigations
• Environmental Training, Awareness, and Competence
• Planning for Environmental Matters
• Maintenance of Records and Documentation
• Pollution Prevention Program
• Continuing Program Evaluation and Improvement
• Public Involvement and Community Outreach
The guidance also provides information about how the criteria can
be incorporated into a settlement document.
To date, the EMS model has been included in several EPA
settlement agreements when both parties have agreed that
improvements in the facility's EMS were warranted.
-------
EMS Framework Comparison
Responsible Care®
ISO 14001
NEIC EMS Criteria
Policy and Leadership
Guiding Principles; policy attributes are defined by the
Management Systems Verification protocol (A.1 to
A.7)
Environmental Policy (4.1)
Management Policies and Procedures (1)
Planning
Planning attributes are defined by the Management
Systems Verification protocol (B.1 to B.7) and
include:
• Identifying relevant regulations and standards
• Evaluating product, process, and distribution risks
• Identifying employee and community concerns
• Setting priorities and goals
Environmental Planning (4.2)
• Environmental Aspects
• Legal and Other Requirements
• Objectives and Targets
• Environmental Management Program(s)
Organization, Personnel, and Oversight of EMS (2)
Accountability and Responsibility (3)
Environmental Requirements (4)
Planning for Environmental Matters (8)
Implementation,
Operation, and
Accountability
Implementation attributes are defined by the
Management Systems Verification protocol (C.1 to
C.11) and include:
• Roles and responsibilities for achieving goals
• Communication
• Procedures
• Employee training
• Documentation
• Pollution prevention
Implementation and Operation (4.3)
• Structure and Responsibility
• Training, Awareness, and Competence
• Communication
• EMS Documentation
• Document Control
• Operation Control
• Emergency Preparedness and Response
Assessment, Prevention, and Control (5)
Environmental Training, Awareness, and Competence (7)
Maintenance of Records and Documentation (9)
Pollution Prevention Program (10)
Public Involvement/Community Outreach (12)
Performance
Measurement and
Corrective Action
Performance measurement and corrective action
attributes are defined by the Management Systems
Verification protocol (D.1 to D.6) and include:
• Performance data tracking
• Accident investigation
• Record keeping
• Audits
• Program effectiveness measurement
Checking and Corrective Action (4.4)
• Monitoring and Measurement
• Nonconformance and Corrective and
Preventive Action
• Records
• EMS Audit
Environmental Incident and Noncompliance
Investigations (6)
Management Review
and Reporting
Management review attributes are defined by the
Management Systems Verification protocol (E.1 to
E.4).
Management Review (4.5)
Continuing Program Evaluation (11)
-------
EMS Framework Comparison
Responsible
ISO 14001
NEIC EMS Criteria
Source of More
Information
CMA's Responsible Care® department is a valuable
resource for CMA's members and partners. Those
seeking more detailed information about Responsible
Care® or the Partner Program should call
(703) 741-5303. Those companies that may not
be interested in CMA membership or participation in
the Partner Program, but that find themselves struggling
and needing assistance in implementing an EMS,
should contact their state chemical industry council.
In October, 1997, EPA published the ISO 14000
Resource Directory (EPA/625/R-97/003). The goal
of the document is to inform readers about the ISO
1 4000 standards and activities. The document can be
accessed through:
The NEIC guidance document, Compliance-Focused
Environmental Management System-Enforcement
Agreement Guidance (EPA 330/9-97-002) can be
accessed through:
-------
APPENDIX F
RESPONDENT RECOMMENDATIONS
RELATED TO SPECIFIC STATUTES
-------
RESPONDENT RECOMMENDATIONS
RELATED TO SPECIFIC STATUTES
Respondents to the Root Cause Analysis Pilot Project survey offered many
recommendations related to specific statutes. These recommendations were
categorized in four categories: compliance assistance recommendations,
changes in EPA policy, regulatory changes, and statutory changes. The
recommendations are identified by statute in the following tables. No
recommendations related to the Comprehensive Environmental Response,
Compensation, and Liability Act (CERCLA) were provided.
Clean Air Act
Individual respondents suggested that EPA implement the following
initiatives under the Clean Air Act (CAA).
Compliance Assistance Recommendations —
New Source Performance Standards (NSPS) rules:
• Publish notices in the Federal Register that provide reminders of
compliance deadlines
• Provide reminders of deadlines under specific rules through list serves
on the Internet
National Emission Standard for Hazardous Air Pollutants (NESHAP)—for
vinyl chloride
• Exclude releases to flares from reporting requirements
Allow reduced frequency of monitoring in light of a facility's leak history (40
Code of Federal Regulations [CFR] part 63 subpart F)
Changes in EPA, Policy —
Make the 1992 "draft" control technique guidelines for industrial
wastewater systems final
NSPS rules:
• Allow enforcement discretion for facilities that meet the intent of the
regulations and rules, but do not meet the prescriptive record keeping
and reporting requirements
• Extend the time allowed to come into compliance with new rules
Regulatory Changes —
Consolidate fugitive emissions rules into one set of requirements
NSPS rules:
• Extend the compliance date for existing rules
NESHAP for asbestos:
• Regulate waste manifest requirements under the Resource Conservation
and Recovery Act (RCRA) or state solid waste rules, rather than under the
CAA
F-2
-------
Allow reduced frequency of monitoring under the Hazardous Organic
NESHAP in light of a facility's leak history (40 CFR part 63 subpart F)
Statutory Changes —
NSPS rules:
• Modify the effective date for new sources, making it the date the rule
actually becomes final
Implement a 10-year moratorium on all new CAA rules so facilities can achieve
compliance with existing rules
Clean Water Act
Individual respondents suggested that EPA implement the following
initiatives under the Clean Water Act (CWA).
Regulatory Changes —
Allow the use of chemical oxygen demand (COD) to screen for compliance
with the requirements governing biochemical oxygen demand (BOD)
Emergency Planning and Community Right-to-Know Act
Individual respondents suggested that EPA implement the following
initiatives under the Emergency Planning and Community Right-to-Know
Act (EPCRA).
Compliance Assistance Recommendations —
Clarify the instructions and guidance for completing Form R
Provide better outreach on instructions for completing Form R
Changes in EPA Policy —
Provide revised reporting forms to industry well in advance of compliance
deadlines
Change the instructions for Form R to indicate that transitory, nonisolated
intermediates are not "manufactured" and therefore such materials should not
be subject to threshold determinations for Form R reporting
Regulatory Changes —
Raise reportable quantities for reporting of releases
Address the applicability of reporting requirements to transitory nonisolated
intermediates through rule making
Simplify the rules for completing Form R
Statutory Changes —
Develop a more reasonable small source exemption
F-3
-------
Resource Conservation and Recovery Act
Individual respondents suggested that EPA implement the following
initiatives under the Resource Conservation and Recovery Act (RCRA).
Compliance Assistance Recommendations —
Develop plain-language guidance for compiling all requirements pertaining
to satellite accumulation
Develop a subpart CC self-audit check list
Develop plain-language guidance for the boiler and industrial furnace (BIF)
rule
Regulatory Changes —
Relax monitoring requirements for BIFs
Revise 40 CFR section 264/65.193 (e)(l)(iii), containment and detection of
releases, to consist entirely of a performance standard
Eliminate in-process materials from the definition of solid waste
Allow as many as 55 gallons of each waste code in satellite accumulation areas
Toxic Substances Control Act
Individual respondents suggested that the EPA implement the following
initiatives under the Toxic Substances Control Act (TSCA).
Regulatory Changes —
Narrow the scope of reporting requirements under section 8(e)
Statutory Changes —
Eliminate reporting for exports that contain chemicals listed in section 12(b)
F-4
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F-5
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