NON-CONFORMANCE, INCIDENTS, COMPLAINTS AND CORRECTIVE ACTION

Terms & Definitions covered by this procedure

• Non-conformance: A problem/situation/incident that has failed to meet planned arrangements or requirements.
• Complaint: A nonconformance that is identified/reported by an external party, such as a customer.
• Corrective Action: Steps taken to rectify/resolve the nonconforming situation, address the cause and to avoid/mitigate recurrence of the situation.

Identification & Recording

It is the responsibility of all individuals conducting work on behalf of the organisation to report all nonconformances to management (these are improvement opportunities).  It is management’s responsibility to record the event, investigate the cause, and implement appropriate corrective actions.

All customer complaints and significant operating problems (Nonconformance) shall be recorded onto a Nonconformance/Complaint Report Form and entered into the Non-conformance/Complaints Log.     

Accidents/near misses or environmental incidents will be investigated using the Incident Investigation Form.

Non-conformities do not include minor issues on site, day-to-day discussions, queries or comments by customers, delays or technical issues that are resolved immediately on site or by email or telephone, or ‘snagging’ (works incomplete or defective on site as part of a final inspection, but which are easily resolved).

Non-conformities can include environmental incidents or ‘near-misses’.

Non-conformities are significant if they:

• Cause serious delays, issues, re-work/cost or non-compliance with standards or the law
• Cause major customer or third party dissatisfaction or disruption
• Jeopardise or cause a contract to be cancelled
• Involve an outside enforcement agency
• Are raised during an audit or assessment by a 2nd or 3rd party body

Complaints are significant if they:

• Are escalated to the level of a Manager or Director to resolve
• Are made formally in writing or by email
• Jeopardise a contract, future work, or the reputation of BCS

Investigation

Management shall consider each identified nonconformance to clarify the direct and root causes.  Steps taken, or to be taken, to rectify and resolve the situation shall be established and implemented.  If the non-conformance involves an external party such as a customer or supplier, clear communication relating to the response shall be ensured.  If the nonconformity may be batch related, potentially affecting other situations/locations/clients, the need to intervene must be considered, if a similar issue could arise elsewhere.  Instruction shall be given regarding the disposition of nonconforming product/service and records of the above shall be added to the Non-conformance/Complaints Log.

Accidents/near misses or environmental incidents will be investigated using the Incident Investigation Form.

Corrective Action

Following rectification of the individual nonconformity (i.e. addressing the problem), management must then consider what Corrective Actions are necessary to avoid the recurrence of (or mitigate the effect of) a similar nonconformity in the future (i.e. addressing the root cause).  These corrective actions may be established at the time of the event and/or within periodic evaluations/meetings.  All corrective actions should be recorded onto the Nonconformance/Complaint Report itself, or within the records of the periodic evaluations/meetings.

An annual Management Review is carried out.  This review will re-assess all nonconformities recorded within that period, identifying any trends, or recurring problems and verifying whether ‘corrective actions’ which have been established have effectively addressed the causes of problem and prevented recurrence. 

Review of Effectiveness

After a period of time, the effectiveness of the corrective or preventive action will be tested, either by routine investigation, or as part of an internal audit programme, to ensure it remains effective.   If the corrective action has NOT been effective, and requires further action, the non-conformance shall remain open on the Non-conformance/Complaints Log.

If the corrective action appears to be effective and there is no further problem, the non-conformance can be closed on the Log.