ABC COMPANY LIMITED

OCCUPATIONAL HEALTH & SAFETY

MANAGEMENT SYSTEM MANUAL
PROCEDURE FOR NON-CONFORMITY HANDLING AND CORRECTIVE ACTION

1. PURPOSE:

To establish, implement and maintain a process, including reporting, investigating and taking action, to
determine and manage nonconformities.

2. SCOPE:

All OH&S related nonconformities.

3. DEFINITIONS:

NIL

4. REFERENCES:

ISO45001:2018 Standard - Clause 10.2 : Incident, nonconformity and corrective action

HMR-H-M-PR-15 : Procedure for Incident Investigation

5. AUTHORITY AND RESPONSIBILITY:

OH&S Management Representative (HMR)

The OH&S Management Representative (HMR) is overall responsible for the implementation of this procedure.

The HMR is authorised to provide resources for implementing OH&S corrections / corrective actions that cut
across departments.

Heads of Departments (HODs)

The HODs are responsible for the implementation of this procedure in their respective departments.

The HODs are authorised to provide resources for implementing OH&S corrective / preventive actions that are
confined to their respective departments.

6. METHOD:

Our organization understands that the reporting and investigation of nonconformities without undue delay can
enable hazards to be eliminated and associated OH&S risks to be minimized as soon as possible.

Some examples of nonconformities are…

- protective equipment not functioning properly
- failure to fulfil legal requirements and other requirements
- prescribed procedures not being followed

Prepared by Reviewed & Approved by Issued by Doc. Control

Doc ID: HMR-H-M-PR-16
Signature Version: 001
Date 01-Apr-2018 01-Apr-2018 01-Apr-2018 Effective date: 01-Apr-2018
Designation HMR MD HMR Page 1 of 4
 ABC COMPANY LIMITED

OCCUPATIONAL HEALTH & SAFETY

MANAGEMENT SYSTEM MANUAL
PROCEDURE FOR NON-CONFORMITY HANDLING AND CORRECTIVE ACTION

When a nonconformity occurs, the organization would …

a) react in a timely manner to the nonconformity and, as applicable:
1) take action to control and correct it
2) deal with the consequences

b) evaluate, with the participation of workers and the involvement of other relevant interested parties, the
need for corrective action to eliminate the root cause(s) of the nonconformity, in order that it does not
recur or occur elsewhere, by:
1) investigating the nonconformity
2) determining the cause(s) of the nonconformity
3) determining if similar nonconformities have occurred, or if they could potentially occur

c) review existing assessments of OH&S risks and other risks, as appropriate

d) determine and implement any action needed, including corrective action, in accordance with the
hierarchy of controls (i.e., eliminating hazards; substituting with less hazardous materials; redesigning
or modifying equipment or tools; developing procedures; improving the competence of affected
workers; changing the frequency of use; using personal protective equipment) and the management of
change (clause 8.1.3)
e) assess OH&S risks that relate to new or changed hazards, prior to taking action
f) review the effectiveness of any action taken, and
g) make changes to the OH&S management system, if necessary.

The steps involved are outlined below:

Non-conformity reporting:

In the normal course, Department Heads report any OH&S non-conformities that took place in their functional
area to the OH&S Management Representative (HMR).

In case a worker reports potential or actual problems to their superiors, the concerned Department Head
conducts a preliminary enquiry and then reports the incident to the HMR.

Periodic OH&S Management System Audits (both internal and external) also aim at identification of non-
conformities and reporting to the management.

Once a nonconformity is identified, it is investigated to determine the root causes and the correction / corrective
action is focused on the appropriate part of the system.

Non-conformity investigation:

After considering various aspects of the incident, the OH&S Management Representative (HMR) assigns
competent personnel to carry out investigations.

Note: In case of a non-conformity reported in an internal / external OHSMS audit, the concerned auditee is
expected to investigate the root causes and offer corrective actions.

Prepared by Reviewed & Approved by Issued by Doc. Control

Doc ID: HMR-H-M-PR-16
Signature Version: 001
Date 01-Apr-2018 01-Apr-2018 01-Apr-2018 Effective date: 01-Apr-2018
Designation HMR MD HMR Page 2 of 4
 ABC COMPANY LIMITED

OCCUPATIONAL HEALTH & SAFETY

MANAGEMENT SYSTEM MANUAL
PROCEDURE FOR NON-CONFORMITY HANDLING AND CORRECTIVE ACTION

Investigation process:

The person / team duly assigned to conduct the investigation carries out a time-bound root-cause analysis and
submits a report to the OH&S Management Representative (HMR).

Root cause analysis refers to the practice of exploring all the possible factors associated with a nonconformity
by asking what happened, how it happened and why it happened, to provide the input for what can be done to
prevent it from happening again. This analysis can identify multiple contributory failures, including factors
related to communication, competence, fatigue, equipment or procedures.

The outputs from the nonconformity investigation processes include the following:
- determination of underlying OH&S deficiencies and other factors that might be causing or contributing to
the occurrence of nonconformities
- identification of corrective action (s) needed
- identification of opportunities for preventive action (s), and
- identification of opportunities for continual improvement.

The leader of investigation team submits the ‘OH&S Non-conformity Investigation Report (HMR-H-F-PR16-
001)’ to the HMR.

Note: In case of a non-conformity reported in an internal / external OHSMS audit, if the concerned auditee
investigates the root cause and offer corrective actions, he / she would write down the root cause and corrective
action in the audit note / audit report itself.

Documentation and communication of findings of investigation:

The HMR retains documented information as evidence of:

- the nature of the non-conformity and any subsequent actions taken
- the results of any action and corrective action, including their effectiveness.

The HMR communicates this documented information to relevant workers / workers’ representatives, and other
relevant interested parties.

Taking actions:

Corrective actions appropriate to the effects or potential effects of the non-conformities encountered are taken.

7. RECORDS:

The following record (s) are maintained.

Sl. Retention Custodian(s)
No. Record Title / ID Format Medium Period
1 OH&S Non-conformity Investigation Report English, Text Paper Min 3 years HMR
(HMR-H-F-PR16-001)

Prepared by Reviewed & Approved by Issued by Doc. Control

Doc ID: HMR-H-M-PR-16
Signature Version: 001
Date 01-Apr-2018 01-Apr-2018 01-Apr-2018 Effective date: 01-Apr-2018
Designation HMR MD HMR Page 3 of 4
 ABC COMPANY LIMITED

OCCUPATIONAL HEALTH & SAFETY

MANAGEMENT SYSTEM MANUAL
PROCEDURE FOR NON-CONFORMITY HANDLING AND CORRECTIVE ACTION

8. DOCUMENT AMENDMENT HISTORY:

Version No. Summary of changes from previous version of the document Changes sought by Remarks of HMR
V-001 First version released for implementation. N/A Nil

Prepared by Reviewed & Approved by Issued by Doc. Control

Doc ID: HMR-H-M-PR-16
Signature Version: 001
Date 01-Apr-2018 01-Apr-2018 01-Apr-2018 Effective date: 01-Apr-2018
Designation HMR MD HMR Page 4 of 4