Non conformities detailed herein shall be addressed through the organization’s corrective action process, in accordance with the relevant correc tive action requirements of the audit standard.
Hereunder you will find Bureau Veritas Certification requirements for:
• expected timelines to address the nonconformity (a)
• response content (b)
Expected timelines to address the non conformity (a)
Corrections and Corrective actions (if possible) to address identified major nonconformities shall be carried out immediately. Correction, Root Cause Analysis and Corrective action plan together with satisfactory evidences of implementation shall be submitted within 90 days after the last day of the audit unless Bureau Veritas Certification and client agree on a longer period of time.
Review of nonconformities is done through desktop review. However, depending of severity of the findings, our auditor may perform a follow up visit to confirm the actions taken, evaluate their effectiveness, and determine whether certification can be recommended or continued.
For a minor nonconformity, correction, root cause analysis and corrective action plan shall be approved by the team leader and verification of implementation and effectiveness of corrective action(s) taken will be performed at the next visit.
It is recommended that the Client provide responses early to allow time for additional reviews if needed.
For recertification time limits to address nonconformities will be defined by the team leader in order to have them implemented prior to expiration of certification.
Any responses to the nonconformities which were raised may be either in hard copy or electronically using the NCR herein (preferred) and forwarded to the Bureau Veritas Certification office.
Expected response content (b)
Client response to NCR should be reviewed by the lead auditor in three parts; correction, root cause analysis and corrective actions.
In reviewing the three parts, the auditor looks for a plan and then evidence that plan is being implemented.
Correction
1. The extent of the nonconformity has been determined (NCR has been corrected & the client has examined the system to see if there are other examples that need to be corrected). Ensure that correction answers the question “Is this isolated case or not?” in other words “Is there a risk that this can reoccur at the other site / department?”
2. If correction cannot be immediate; a plan to correct the NCR may be appropriate (responsible & date).
3. Evidence that the correction was implemented or evidence that the plan is being implemented.
Root Cause Analysis
1. The Root Cause is not simply repeating the finding, neither is the direct cause of the issue.
2. Well thought out analysis to determine the true root cause: e.g. someone did not follow a process would be direct cause; determining why someone did not follow a process would lead to the true root cause.
3. The root cause statement must focus on a single issue without any obvious """"""""why"""""""" questions remaining.
If a """"""""why"""""""" question can reasonably be asked about the root cause analysis, this indicates that the analysis did not go far enough.
4. Ensure that the root cause answers the question, “What in the system failed such that the problem occurred?”
5. Blaming the employee will not be accepted as the only root cause
6. Address problems with the process as well as what detection system failed
Corrective Action
1. The corrective action or corrective action plan addresses the root cause(s) determined in the root cause analysis. If you have not defined true root cause you cannot prevent the problem from its reoccurrence
2. In order to accept the plan it shall include;
actions to address the root cause(s)
identification of responsible parties for the actions and
a schedule (dates) for implementation.
always include a “change” to your system. Training and/or publishing a newsletter are generally not changes to your system
3. In order to accept the evidence of implementation:
a. Enough evidence is provided to show the plan is being implemented as outlined in the response (and on schedule).
b. Note: Evidence in full is not required to close the NCR; some evidence may be reviewed during future audit when verifying the corrective actions.