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PR09 Non-Conformity Procedure Version

This document outlines the procedure for handling non-conformities, corrective actions, and preventive actions within the Sustainability Management System (SMS) at the University of Greenwich. It defines key roles for identifying and investigating non-conformities, and taking corrective and preventive actions. It also describes procedures for recording non-conformities, actions, and changes to procedures in an action request log and internal audit reports. The goal is to ensure non-conformities are addressed and prevent recurrences.

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0% found this document useful (0 votes)
67 views

PR09 Non-Conformity Procedure Version

This document outlines the procedure for handling non-conformities, corrective actions, and preventive actions within the Sustainability Management System (SMS) at the University of Greenwich. It defines key roles for identifying and investigating non-conformities, and taking corrective and preventive actions. It also describes procedures for recording non-conformities, actions, and changes to procedures in an action request log and internal audit reports. The goal is to ensure non-conformities are addressed and prevent recurrences.

Uploaded by

Ali Kaya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Site: All Campuses Approved by: Kat Thorne

Version: Department: Facilities Management


Issue date:

PR09: SMS Non-conformity, Corrective Action & Preventive Action Procedure

(ISO 14001 section references 4.5.2 & 4.5.3)

Purpose
To ensure that all non-conformities are reported and that action is taken to correct and
prevent future non-conformities.

Scope
This procedure covers all activities by the FM team at the University of Greenwich at the
three sites covered by the Sustainability Management System (SMS) – Avery Hill, Medway
and Greenwich.

Definitions
Corrective action:- action to eliminate the cause of a detected nonconformity.

Non-conformance:- reported via the auditor when the objective evidence of an auditor
reveals that activities are either not in compliance with the relevant components of the
SMS, the SMS is not being implemented effectively, or, the SMS as implemented does not
comply with the requirements of the standard.

Preventive action:- action to eliminate the cause of a potential nonconformity.

Procedure for non-conformities, corrective action and preventive action

1.1 Roles and responsibilities


Appropriate and timely corrective action must be taken according to the nature of the non-
conformance. Preventive action, such as modifying procedures or controls, must be taken to
avoid repetition of the non-conformance.

All FM staff will comply with all corrective and preventive actions prescribed within their
sphere of responsibility. In exceptional cases, they should inform the Head of Sustainability
of reasons why actions cannot or will not be taken, for further consideration and decision.

1.2 Identification
Non-conformances and observations can be identified through a range of activities,
including:

 Internal audit findings


 Third party audit findings

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Version: Department: Facilities Management
Issue date:

 Complaints
 Observation
 Incidents
 House-keeping inspection
 Near-misses

1.3 Investigation
Whenever a non-conformance is identified, the underlying cause(s) must be investigated.
This can be done by discussing the non-conformance with other members of the FM team,
especially those familiar with the area or subject of concern.

1.4 Corrective and preventive action


Once identified, the non-conformance and resulting actions must be reported to the
Sustainability Team to be entered into the SMS Action Request Status Log – CD10. This can
be done, for example, via email, through internal audit reports or incident report forms. All
progress against actions should also be sent to the Head of Sustainability on a regular basis
until all actions have been verified as closed.

The Head of Sustainability is responsible for collating all SMS Action Requests into CD10 and
is also responsible for monitoring progress against actions, evaluating trends in actions and
presenting findings to the Management Review.

Where preventive actions involve long term programming, these will be considered in the
setting of objectives or targets.

1.5 Record keeping


The Sustainability Team will maintain a system of reporting and record keeping for non-
conformances, corrective and preventive action. This will be done primarily through
uploading completed internal audit reports to the FM Shared IT Drive and through the
maintenance of the SMS Action Request Status Log, CD10.

Any changes to the SMS procedures as a result of corrective or preventive action will be
recorded.

Related documentation
CD10 – SMS Action Request Status Log
PR10 – Internal SMS Audit
SF02 – Internal SMS Audit Report

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Check validity with list of documents on shared drive ‘U:OFM/FM Shared/ISO14001_SMS_Shared’ before use
Site: All Campuses Approved by: Kat Thorne
Version: Department: Facilities Management
Issue date:

Changes to this document


If you think changes are required please contact Alex Giles, Sustainable Projects Assistant,
on x8813 or email sustainability@gre.ac.uk. If necessary, changes to this document will be
made and recorded below, and a new version will be created.

Version no. Change made Name Date


updated updated

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