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hi everyone my name is James Tigran I am with risk management professionals today we'll cover the Nevada division of environmental protection or ndep document control system which includes methods of developing document control had a Nevada facility and how the nDEP chemical accident prevention program or CA PP commonly set as cap document control system is audited this is part of a series of presentations while broadcast on how to better achieve compliance with cap regulations as a little bit of short background this webinar series is a part of our MP's larger ongoing outreach program our core competencies and expertise resided in nevada cap epa RMP osha p assam Cal r and sense program development has often lopa studies and other hazard identification techniques and finally a variety of other process safety and regulatory standards and regulations for this document control webinar we're going to first go over a Rayleigh tour overview in order to characterize how document control fits into the overall cap program then we're going to go ahead and define document control and its requirements we're gonna go over the general management management of document control to different methods of document control and finally look at how document control systems are audited one of the great things about Nevada's cap program is that it provides a lot of resources for each facility to become compliant with kaif regulations Nevada's website provides the tools necessary to develop and hone compliance programs provides comprehensive guidance for determining what programs apply to each process based on threshold quantities and even uses conversion factors for calculating and comparing quantity on hand to threshold quantities so the tools are really at the fingertips of each facility to look at their facility analytically in their processes and determine what kind of cover tonight is necessary for their facility the focus of the program is for owners and operators to implement moral programs that fit with an organizational culture this increases the practicality of program compliance and generates a safer environment again there are conversion factors for temperatures parts per million stoic geometry and other important units in relative regulatory language and the website also provides source links to regulations like the Code of Federal Regulations which may also apply to each facility and finally it has guidance for each element item and an on a grading sheet which is used by regulators to conduct program evaluations on a numerical basis cap audits all similar to others have a much more structured approach to the audit process than other regulatory agencies and these grading systems are used during each audit at the table below you see the threshold quantities that are used to determine program coverage therefore regulated chemicals and they're really similar to the Environmental Protection Agency or EPA and the occupational safety hazard Association our OSHA regulations a list of some differences are listed with the cap being the most stringent cap also distinguishes to release threshold for facilities that have had multiple releases at the facility and that's where you see the middle column which is denoted cap - and that represents if a release has occurred at least twice within a one-year period at a facility as you can see elements and requirements are similar to other programs such as OSHA PSN and EPA RMP in most cases one program can be developed that will address all the requirements of different agencies - exceptions here are that the cap has requirements for a more in-depth document control and management system which you see in the table on the right-hand side on the current guidance documents there are specific elements pertaining to these items that are required to interact with all of the other cap elements you see in the diagram on the left hand side today we'll focus on document control a variety of document control practices are required of regulated facilities by US regulation the term document control refers to a group of information management practices related to documents document control practices normally include provisions to ensure the documents are available to staff who need them our current have been properly authorized by the director or by someone the director appoints this could also refer to any kind of administrator or manager and finally it requires that documents are properly archived from taken out of service a lot of times document control systems result in a document control procedure or document that basically characterizes the entirety of the procedures and the requirements at the facility for document control the program must itself be controlled as well the program is developed to conform to cap regulations and must describe the who what when where and how of document control at the facility so when going through the document control program we commonly advise to document what initiates a document can trick change which is specific to qualitative events that warrant a change so instead of saying that a significant change occurs to one of the cap elements you would have to characterize how to qualify how to qualitatively evaluate what would be a major change this would include an administrative update to document does that warrant a change in version of the document or if a procedure has changed does that warrant a change to your document control also ask do personnel need to be trained on this change also ask how controlled copies of documentation are identified who approves the changes can initiate changes and manages implementation and are any documents restricted by answering these questions within your document control program you'll already be ahead of the process in developing your entire document control procedure document control is found within the Nevada Administrative Code or NAC for 59.95 341 management and implementation plan thus it's commonly thought that the document control system and management system are synonymous however differences in either program often lead to facilities developing separate plans for document control systems that have specific requirements interconnecting with the management plan the cat that dress is document control and its Nevada Administrative Code the cap identifies five specific elements that are required to demonstrate document control these include the first meaning documents are required to demonstrate document control which although it seems a little redundant it's a broad statement that will apply to requirements including how documents are controlled what documents are controlled while they're controlled etc going through those same questions that we just went through the who what when where why and how this applies to the lifecycle of each document under cap program requirements for example if looking at the mechanical integrity program or mi program it would need to be controlled such that any changes to equipment are correctly documented in personnel whose jobs are affected by the change are informed of that change and also of the new document and where to find the document looking at number two there should be evidence that personnel have read documents relative to their job activities there are further requirements under the training program but for document control the system should describe how it is verified and where verification can be found such that employees have reviewed them and can access them building off of our mi program change example consider when a change occurs to the mi program how our personnel informed of the change do they have access to older files when thinking about this access to older files could lead to the older file is being used place of the new files this could threaten the system by leading to its operation outside of permissible operation limits or the design intent of the equipment the document control program should know how employees are made aware of changes and ensure their current copies are used in place of all document versions furthermore significant changes will lead to another cycle of employer from you this means that a significant change must be defined and qualified for each facility moving on the number three documents should be properly authorized before being placed into service this lends itself in it to a management structure at the facility where person processes and changes documents as necessary moving on the number four documents are to be reviewed by an authorized individual at least annually the cap program is comprised of living documents these documents change as the facility develops in a case where facility does not undergo any changes within a time period of about a year that could mean that no document review is engaged from a facility an annual review that is thus required and present to ensure that any changes that may have occurred were appropriately implemented and incorporated of tap and into the capital requirements in the facility structure another strategy would see in order to ease these requirements into the company culture is to ensure that these annual reviews are adequately documented this can be conducted by having authorized individuals sign off on something that is verified or by adding an additional control document that contains the revision date and history of each document for the year finally at number five discontinued documents are to be retained for a minimum of two years after the date of discontinuation this just as a method of document retention and it's an important characteristic for consistency efficiency and that also protects facilities from liability to better explain the application of hierarchy what follows here are common delineations of responsibility you see with cap programs document control systems are not cookie cutter and will change according to the facility it's applied to you this includes variability in their resources size etc at the far left we have directors which is synonymous with management or administrators it can be a single person or a team of people and the person or people can be designated based on their ability this position has the responsibility to authorize document versions and changes this position ensures that the most current information is in use ensuring the most current information is in place can be tricky when a draft is lost or changed without being transmitted to individuals that are using that document so this type of responsibility would fall under the director moving to the right we have supervisors or managers this position implements an issues documentation recall that there should be evidence that personnel have read documents relevant to their job activities some type of manager or supervisor would be responsible for checking that the documents demonstrate document control and ensure that there is evidence that personnel have read and understand the documents relative to through job activities finally we have workers workers will have to understand and provide feedback on implementing procedures the role of workers is to engage implementation of each cap element there are a wealth of information connecting the written procedures to how actual documents like procedures are applied in the field by obtaining feedback on the procedures the documents can be updated and home to reflect how they are actually used by workers so these are going to be living documents that we're talking about they are the most accurate when they precisely reflect how workers are performing tasks in the field it is the responsibility of administrators to provide an avenue for feedback on each document from the workers both priorities have the responsibility of communicating feedback responsibility for updating each document is delineated within the document control program and we commonly see that directors in this structure would be the party responsible for updating the document controls for feedback to be both voiced by workers and heard by administration it's important for the company culture to be shaped so that there is no resistance in communicating the message individuals working on the process provide a lot of driving force and giving feedback and adjusting documents to fit the process there are many cases where operators may change the way things are done without documenting the procedures and updating the procedures accordingly this leads to cap in a program that can be caught by regulators leading to issues in compliance audits later on the company culture would have to reflect the priority of communication and adjustment of to procedure in order to facilitate fluid program operations feedback is also a part of other cap elements including training so in all these responsibilities can be implemented using a physical or electronic copies of procedures and these two items physical or electronic copies they have a couple of distinct differences first looking at physical document control physical document control can be very practical way to implement the document control requirement of cap covered facilities and it can be a common strategy that's used to reduce costs for smaller facilities by removing the overhead associated with document control software there are specific details that must be covered when using physical document control which follow changes will be evaluated and applied in the same manner as in an electronic access model in this case however some type of marking the document must be made this can be a watermark or date current copies must be put into circulation instead of having this automated on a computer in an electronic system the document control system when to have a specific procedure for distributing current copies and ensuring the previous versions of the procedures are archives with physical copies of document control there will also need to be a place for storage of older files the procedures must address how older copies are retained for the currently required two years and what happens after those two years have expired would the facility shred the documents or store them for longer before disposing of them the individual responsible for this task and how it is conducted must be identified as well finally the location of storage of current copies must be identified many documents must be readily available to workers so controlled copies would need to be at the facility this could lead to controller copies being updated and maintained in two different locations furthermore the location of the encode uncontrolled documents needs to be described in the document and followed accordingly with rapid advances and online technologies organizations are migrating from paper-based resources to digital documents in order to achieve high responsiveness and ease of management the following are a couple of considerations that should be included in the document control program when using server based document control if a particular file extension is used to access documents such as via SharePoint the global file extension can be listed on the document control policy in order to describe how the documents are accessed access control is an important consideration not only for protection of proprietary knowledge but also to ensure that changes aren't made internally that could lead to lost information or operation of equipment outside of its design and time this can be conducted in a number of ways one of the most common methods is with a protected log-in for administrators the document so the document control system should describe how personnel access this ism whether through the supervisor or directly with a computer the current revision status of the document can be easy when it's on a facility server however what's printed there needs to be some type of description for whether or not the document can be considered controlled I've seen facilities conducting this by staying a length of time such as 24 hours after the time of printing that the document is controlled the length of time should be close enough to the time of printing that it's impractical to assume significant changes have been made to the document before the document is no longer considered controlled so this would infer that the date and time of printing is in luded on the document when printed and it would also infer that there's some kind of disclaimer printed on the document stating an employment will no longer be considered controlled so after that time limit that we just discussed many facilities have more chemicals than those that are covered by cap thus many policies may be included in the elements required and thus don't need to be required controlled a list of all procedures covered by the document control policy is also a useful approach to tracking each document that is controlled this can be included within a table on a document control policy and the reason for its location on a document control policy is because it's going to need to be controlled and updated according to the policy during each revision the document control policy must also be maintained by a specific person or persons so this too would need to be listed on the document control policy for server based documents so with the physical based document control system each documents going to be controlled according to a management structure that's right now in the document control system normally it would assign one person as responsible or a team of persons as responsible for the entire program with server based document control there's a bit of ambiguity in how documents are accessed and who has permission which is defined within the software code so I find it helpful to have some kind of a blog flow diagram illustrating the access points of the policy server thus here we have a block diagram that illustrates a policy server that centrally managed with policies that are used by workstations and servers the rules for this should be designed so that only controlled copies are in circulation preventing the use of old procedures that have the potential for the process to operate outside of its new design intent because it's difficult to determine if a user has permission to access a file different approaches have been developed one solution is where systems use a simple approach to determine if the user has a permission to access a file it then delineate permission for reading writing and executed in this case the permissions are applied to three types of users the owner of the file the group that the owner belongs to and the other users another is where permission is granted to those users that need access to the file document management systems can require a user to check the document in and out of a library system once the document has been checked out it can be distributed and modified in any manner this means that there's no control over how a document is used once it leaves the document management system for those documents that are needed in hand when being applied such as operating procedures for system operations or preventative maintenance tasks a watermark as simple as the date and time of checkout can be printed with the file and then used in the field since the controlled copy of each document is maintained on the server printed copies of any forms and procedures or work instructors derived from the server would be considered uncontrolled and should be verified against the server documentation prior to use in cases where the user determines that the document is obsolete the document should be discarded immediately and if these are used at a particular facility these would have to be included within the document control procedure once a document control procedure is developed at a facility it needs to be maintained and prepared for each annual audit this is an example of one of the checklists on any EPM be gov that can be used to maintain programs internally this checklist can be used as a starting point and has intended to be comprehensive these forms are very useful in the integration of internal facility audits in order to maintain compliance and increase efficiency the document control requirements are listed along with the management system requirement in each cap requirement but that a strategy for developing these programs can differ differ significantly the element audit checklist presents an expert from the checklist used by auditors to grade programs the contents of the forum provide an overarching description of ensuring that the most current information is in circulation in use which can be applied and accomplished using the strategies we've already discussed the data form is meat available to help describe how the facilities can meet cap requirements regulations outline the general requirements however the cap audit checklist specific information is required if applicable for the process safety information as shown in the example on this slide the system must describe in detail how information is processed at the facility clearing the cap auditing process of any element including the document control audits are going to be conducted according to the list we just mentioned on the screen we have one example of one of the numerical gradients of the cap audit process after the audit a report will be provided to the facility showing the grading criteria and how the facilities program was evaluated the report can be used as a guide to update and revise safety program information to correct deficiencies resulting from the audit also don't hesitate to contact the regulator with any questions pertaining to what they require in your program in conclusion the document control system provides security liability protection and information efficiency once it's developed and implemented at a facility the roles and responsibilities must be specifically delineated within each document control procedure and different systems can be developed but should fit within the organization's culture so that they can be fully integrated into the day-to-day activities and are not a burden for the facility to follow here is the reference that we used for the development of this PowerPoint you have any questions regarding this PowerPoint you can contact me and my email which is on the screen or at our offices phone number finally you can find more information about our company and some of our other webinars at our website thank you very much and I hope you enjoy your day