UPDATED JANUARY12, 2011

QMS-QUA-03 - Corrective and Preventive Actions

1 1.1

Scope and Application Purpose To ensure that problems, concerns, complaints, suggestions and anomalies concerning the evaluation and certification processes are addressed in a consistent and effective manner and are prioritized according to their magnitude and degree of risk.

1.2

Scope All activities within the evaluation and certification processes.

1.3

Authority Section 18 of the Pilotage Act.

1.4

Responsibilities (1) Every Great Lakes Pilotage Authority employee is responsible for reporting situations that fall within the scope of this instruction. Employees are encouraged to submit suggestions for improvement. Evaluators and Auditors are responsible for reporting situations that may affect the integrity of the evaluation process. These situations may include, but not be restricted to, the standard of evaluation criterias and guidelines, the method of evaluations and opportunities for abuse of the system. The Director of operations and auditors are responsible to the Chief Executive Officer for resolving all problems affecting the preparation of evaluation criterias and guidelines, for the consistency of marking and the equitable application of the evaluation process. The Corrective Action Committee comprising the Chief Executive Officer the Corrective Action Coordinator and the Direction of operations is responsible for prioritizing corrective action requests and for establishing corrective action teams, where appropriate. The Corrective Action Coordinator is responsible for administering the corrective action process, maintaining the corrective action log and issuing status reports. The Chief Executive Officer is responsible for determining departmental policies and for providing adequate resources to the corrective action process.

(2)

(3)

(4)

(5) (6)

1.5

Definitions (1) For the purposes of this procedure and any related documents, the term problem includes concerns, complaints, suggestions and anomalies. Such problems might include the integrity of the evaluation and certification processes, departmental policies, trainees, employees and training establishments. The Corrective and Preventive Action Request (see Annex A) is the document used by employees to submit problems that relate to the work process, the product of such process or client satisfaction. The Corrective Action Team is the team designated to investigate a specific corrective action request to the extent of their mandate. In this context a team may comprise one person.

(2)

(3)

UPDATED JANUARY12, 2011

1.6 Revision Status Insert proper revision dates in the future 2 2.1 Procedure General (1) Where an employee (the Initiator) identifies a problem within the scope of this instruction, he completes and signs a Corrective Action Request form (see Annex A) and submits it to the Corrective Action Coordinator. The Corrective Action Coordinator enters the request into the Corrective Action log (see Annex B), issues a log reference number, forwards the form to the Director of operations and advises the initiator. Should a request be sent directly to the Director of operations, he/she shall obtain a log number. Where a request is received but in a format other than the form itself (i.e. memo or verbally), it shall be transposed onto a form and allocated a log number.

(2)

(3)

2.2

Departmental Action (1) (2) Where the Director of operations is able to do so, he resolves the problem and advises the Corrective Action Coordinator and the initiator. Where the problem is within the competence of the Director of operations but of a more complex nature, the Director of operations may appoint a Corrective Action Team Leader and provides a written mandate. As needed, the leader establishes a Corrective Action Team of appropriately qualified personnel. After review of the project, the Corrective Action team and the Director of operations agree on a target completion date and the resources required meeting that date. The Director of operations advises the initiator of the intended action. The Corrective Action Team carries out its mandate, providing feedback to the Director of operations and Corrective Action Coordinator at agreed intervals. The Corrective Action Coordinator updates the Corrective Action log. The team leader is responsible for maintaining complete records of the project. On completion of the project, the Team Leader presents the conclusions to the Director of operations. Where the teams mandate was to implement a corrective action the Director of operations signs off on the Corrective Action form. Where a recommendation only was mandated and the recommendation is found acceptable, the Director of operations delegates responsibility for its implementation. The Director of operations advises the initiator of the action to be taken. The Director of operations follows up after a reasonable time to ensure the implementation of the solution has resolved the problem.

(3)

(4)

(5) (6)

(7) (8)

2.3

Committee Action (1) (2) Where the problem cannot be resolved by the Director of operations or where the problem involves more than one department, he presents the request to the Corrective Action Committee. The Corrective Action Requests are prioritized by the Committee on the basis of importance and the availability of resources. Where requests cannot be undertaken immediately, they are added to the Opportunity List (see Annex C), maintained by the Coordinator. The Coordinator notes the decision and reason on the form and forwards a copy to the initiator. Where requests are refused, the initiator is informed in the same manner. The Corrective Action Committee activates requests from the Opportunity List based on priority

(3)

UPDATED JANUARY12, 2011

and the availability of related resources such as budget, manpower and expertise. (4) (5) Where appropriate, the Committee designates a Corrective Action Team and team leader and issues a mandate that clearly defines the extent of the teams authorization. The team assigned a Corrective Action Request provides an estimated completion date to the Coordinator and advises him on a regular basis of the progress made. The Coordinator updates the log accordingly. The Team Leader is responsible for maintaining complete records of the assignment. The Corrective Action Coordinator provides the Committee with a regular status report on the active requests and related statistical data. The Committee is responsible for taking action where there has been inadequate progress. The Corrective Action Team presents the completed project to the Committee. Where the teams mandate was to implement corrective action the Committee signs off on the Corrective Action form. Where a recommendation only was mandated and the recommendation is found acceptable, the Committee delegates responsibility for its implementation. The Coordinator advises the initiator that the project is completed. The Committee follows up after a reasonable time to ensure the implementation of the solution has resolved the problem. Files of the Corrective Action Requests are held by the most appropriate of the Coordinator or the Manager. The Coordinator maintains the Corrective Action Log, the Opportunity List and copies of all Corrective Action requests. He makes the log available to all employees involved in the Evaluation and Certification process. The Coordinator provides statistical information on corrective actions to the Committee on a quarterly basis.

(6)

(7)

(8) (9) (10) (11)

(12)

UPDATED JANUARY12, 2011

ANNEXES ANNEX A

CORRECTIVE AND PREVENTIVE ACTION FORM

Initiator: _________________________ Location: ____________________ Log # ___________ Signed: _____________________________ Detail of Problem: Date: ______________________

Corrective Action Team Leader: Members: Mandate: ______________________________________________________________________________ Corrective Action/Recommendations:

Preventive Action/Recommendations:

Signed: __________________________ (Leader) Approved: ________________________ (Manager) Verification of Corrective Action Taken:

Date: ___________________ Date: ___________________

Signed: __________________________ (Manager) Verification of Preventive Action Taken:

Date: ___________________

Signed: __________________________ (Manager)

Date: _________________

ANNEX B

CORRECTIVE ACTION LOG Log Date Initiator Description Leader Latest Activity Date

ANNEX C

CORRECTIVE ACTION OPPORTUNITY LIST

Log

Date

Initiator

Description

Reason for inaction

Date Activated