KOKE Document Type: Document Title: Effective Date: Revision No.

&
ENGINEERING Procedure Non-conformity and OCTOBER 2022 Date
Corrective Action

Document No: Prepared By: Approved: Authorised by:

KOKE-SHEQ- 05 SHEQ Manager SITE MD
SUPERVISOR

NON-CONFORMANCE AND CORRECTIVE ACTION PROCEDURE

1.0 Purpose

1.1 To ensure that Non-Conformities are effectively identified and managed.

1.2 To ensure existing or potential Non-Conformities are expeditiously and effectively dealt
with to prevent any adverse alterations to KOKE SHEQ Management Systems.

2.0 Scope

2.1 This procedure covers all Non-Conformities that relate to KOKE operations.

2.2 The procedure documents corrective and preventive actions aimed at preventing accidents
arising from the materialization of significant hazards, aspects, near misses and quality issues
within the working environment.

3.0 Responsibility

3.1 The SHEQ Manager is responsible for:

3.1.1 The development, implementation and maintenance of this procedure.

3.1.2 Ratifying decisions made by HODs and HOSs in their departments and to ensure that
the agreed corrective actions are implemented.

3.2 HODs and HOSs shall be responsible for:

3.2.1 The prevention and identification of Non-Conformities within their areas of

responsibility.

A PRINTED COPY IS AN UNCONTROLLED COPY UNLESS CONTROL STAMPED

3.2.2 Ensuring that corrective actions to identified deviations are effectively developed and
implemented.

3.2.3 Ensuring that this procedure requirements are communicated, implemented and
maintained in their departments.

4.0 Definition

4.1 MD - Managing Director.

4.2 HOD -Head of Department.

4.3 HOS -Head of Section.

4.4 SO -SHEQ Officer.

4.5 NC -Non-Conformity.

4.6 CAPA -Corrective and Preventive Action.

4.7 SHEQ -Safety Health, Environment and Quality.

4.8 Hazard - Something that has a potential to cause harm

4.9 SM - Safety, Health, Environment and Quality Manager

4.10 SHEQMS -Safety Health, Environment and Quality Management

4.11 Aspects -Anything that can interact with the environment.

4.12 Safety -Freedom from unacceptable risk of harm.

4.13 Quality -Ability to meet customer requirements and consistency in

output.

4.14 Hazard - Source or situation with potential for harm in terms of

human injury or ill health, damage to property, and damage to workplace environment
or a combination of these.

4.15 Non-Conformity -Any deviation from work standard practices,

procedures and regulations which could directly or indirectly lead to injury, illness,
property and environmental damage or a combination of these.

4.16 Corrective Action -Action taken to address the causes of identified Non-
Conformities to prevent their recurrence.

4.17 Preventive Action -Action to eliminate the causes of a potential

4.18 Potential - A situation that has the capacity to cause failure to comply
Non-Conformity with KOKE procedures controls and/or other requirements if not
addressed.
A PRINTED COPY IS AN UNCONTROLLED COPY UNLESS CONTROL STAMPED
5.0 Special Requirements

5.1 All identified Non-Conformities shall be recorded and investigated to ensure their
effective close-out through corrective action development.

5.2 Any deviation to the procedure requirements shall be Authorised in accordance

with the Change Management Procedure requirements.

6.0 Precautionary Requirements

6.1 Raised NCs shall be submitted to the relevant HODs and HOSs who, in
consultation with SHEQ personnel, shall investigate and establish the root causes to
any raised NC.

7.0 Activity Description

IDENTIFICATION OF NON-CONFORMITIES

7.1 HODs, HOSs and all personnel shall identify NCs through, but not limited to:

7.1.1 Customer complaints, both internal and external

7.1.2 Non-Conforming products and services

7.1.3 Job observations

7.1.4 Data analysis

7.1.5 Audit reports

7.1.6 Incidents/accidents

7.1.7 Risk assessment

7.1.8 Regulatory inspections

7.1.9 Management VFLs

7.1.10 Benchmarking

7.1.11 Process performance review

7.1.12 Aspects/hazards monitoring and measurement

7.1.13 Employee suggestions on SHEQ improvement

7.1.14 External communications

7.1.15 Management review meetings

A PRINTED COPY IS AN UNCONTROLLED COPY UNLESS CONTROL STAMPED

7.2 Appointed SHEQ personnel shall check and sign off departmental Customer
Feedback Registers daily and bring any raised complaints to the respective HODs and HOSs'
attention for appropriate action.

RECORDING OF CORRECTIVE ACTIONS

7.3 Any employee can raise an NC and all such NCs shall be recorded on a CAPA
Form and directed to the SHEQ office.

7.4 The SO shall direct the form to the respective department to initiate action and
forward the CAPA form to the SM.

7.5 Corrective action shall be taken according to the nature of the NC and
addressed as soon as possible but within three (3) months.

7.6 Upon receiving a CAPA form, the relevant HOD/HOS shall coordinate and
conduct appropriate root-cause analysis of the NC in liaison with the SHEQ
personnel, to prevent recurrence.

7.7 After investigation of the NC the HOD/HOS shall submit to the SM for
corrective action plan review.

7.8 All persons affected by the NC shall be involved in the investigation and
corrective action process.

7.9 Where NCs have a significant impact on the image and brand of the company,
these shall be directed to the Branding &Marketing office and handled through the
Customer Feedback Handling Procedure.

7.10 HODs and HOSs shall record all raised NCs in NC Registers for effective
tracking. analysis and follow up.

7.11 Potential NCs shall also be addressed through the CAPA forms and proactive
action determined to prevent the ascendance into an NC.

CLOSING OUT OF NON-CONFORMITIES

7.12 The HOD and HOS, in consultation with other relevant personnel/interested
stakeholders, shall put controls in accordance to the Hierarchy of Controls (Eliminate,
Reduce, Isolate, and Protect) for the identified causes of NCs.

7.13 Where it is not possible to eliminate the causes of the NC, the cause is identified
as a hazard or aspect requiring monitoring and for which a procedure shall be
established.

7.14 Action plans for raised NCs shall be attended to within specified periods as
indicated on the CAPA Form.

7.15 NCs shall be classified as follows:

A PRINTED COPY IS AN UNCONTROLLED COPY UNLESS CONTROL STAMPED
 7.15.1 Minor-NC does not have a high risk or potential to stop operations.

7.15.2 Major-Violates a standard documented procedure, legal requirement or

recurring NC.

7.16 The SHEQ department shall follow up with the respective HOD and HOS on the
root cause identification and implementation of appropriate corrective action.

7.17 If the proposed plan is acceptable, the HOS and HOD shall proceed with
implementation of the plan and maintain all records of the action taken to address
each NC.

7.18 The HOS and HOD are responsible for ensuring that all generated CAPA forms
are formally reviewed at a minimum of one (1) month intervals.

7.19 On completion of the corrective action implementation, the SHEQ department or

appointed auditor shall verify the effectiveness of the action taken and sign off the
NC.

7.20 Where the NC persists, the SM, HOD and HOS shall meet to solve the NC.

7.21 Any changes in Standard Operating Procedures, work instructions, etc, resulting
from corrective action plans, shall be done in accordance with Control of Documented
Information Procedure.

A PRINTED COPY IS AN UNCONTROLLED COPY UNLESS CONTROL STAMPED

 8.0 References

8.1 Steel Brands SHE Policy Manual

8.2 Customer Feedback Handling Procedure

8.3 Customer Feedback Registers

8.4 ISO 14001:2015 &ISO 45001

9.0 RECORDS

Record Tittle Where kept Retention Period Disposal Method

NC Register and CAPA SHEQ office 5 years Shredding
forms
Customer Feedback Marketing 5 years Shredding
Register
C Customer Feedback Marketing 5 years Shredding
Forms

10.0 Amendment History

Amendment Amendment Amendment Amendment Amendment
Number Date Details Originator Authoriser

A PRINTED COPY IS AN UNCONTROLLED COPY UNLESS CONTROL STAMPED