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This training session discusses auditor issues related to client processes and provides guidance on NCR responses for correction and corrective action.
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PRI Registrar Quarterly Training 17-Nov-2018
Introduction • As many of you will have heard, PRI Registrar had its ANAB office audit in September. • The office audit resulted in 13 NCRs (1 major, 12 minors), many of which must be resolved through auditor training. • We will be reviewing the findings that relate to auditor issues today.
Client Processes • One NCR we received dealt with the matching of client processes across the audit paperwork, but also implied something more fundamental. • We will discuss: • the requirement directly related to the finding • the deeper implication for how processes are defined • how this relates to PRI Registrar’s process
Client Processes • The NCR was specifically written because there were several examples of client processes not matching across all of the audit documentation (audit plan, audit program, and QMS/EMS Matrix). • While there was a period in which PRI allowed auditors to be more lenient in regards to the matching of process names (equivalent, if not identical), that is no longer the case. • Process names must match exactly everywhere they appear in the audit documents. • This includes the audit program (the RF-117 for Aerospace audits, and the RMS processes for other programs). • Modifications are underway in RMS to unify the audit program across all programs, and to make managing the processes easier.
Client Processes • In addition to the surface issue of process names being identical, is the idea that everything listed on the audit plan, QMS/EMS Matrix, and audit program should be processes rather than activities. • In many cases, clients will not include some standard requirements as part of a fully defined process (usually requirements directly related to the management system). • This is not acceptable. • All standard requirements must be met within at least one of the processes defined in the interaction diagram. • A nonconformance shall be written to any client who fails to include all requirements in their defined processes. • The QMS/EMS Matrix must only list defined processes, and all standard clauses must be associated with at least one of these processes. • In addition, an NCR was issued to PRI regarding all standard clauses not being assessed during the certification cycle. • All clauses must be reviewed at least once during the surveillance audits, in addition to the full system audit (Stage 2 or Recertification). • Please be sure to take individual clauses into account when planning the process audits to ensure all requirements are met.
Client Processes • In order to prevent this nonconformance from recurring, the following instructions are being implemented for audit documentation submitted to PRI Registrar: • Audit Plan (RF-12) • The audit plan must reference only the processes defined by the client on their interaction diagram, and shall not list activities as separate items on the plan. • E.g., if “heat treating” is part of a company’s “manufacturing” process, then heat treating may not be listed as its own entry on the audit plan. • If the auditor wishes to provide a more detailed audit plan that describes activities within a process, they may do so, as long as the process is clearly indicated on the plan. • An example follows on the next slide. • Audit Program (RF-117 or RMS) • Processes listed in the program must exactly match the processes defined by the client in their interaction diagram. • Any scope activities that are added to the audit program for tracking purposes (see Auditor Advisory #109) must be clearly identified as activities and not processes. • A modification to RMS is in process that will make the organization and maintenance of the audit program easier. • QMS/EMS Matrix (RF-129 or IAQG Form 2) • Processes listed in the program must exactly match the processes defined by the client in their interaction diagram. • No miscellaneous “pseudo-processes” may be listed (e.g., “QMS requirements”, or “Non-PEAR processes”).
Client Processes This is a very good example of providing a more detailed audit plan, while clearly identifying activities as part of the client’s defined processes.
NCR Responses • Another NCR that PRI Registrar received was that auditors were accepting weak NCR responses; specifically, two examples were found of auditors allowing clients to perform no correction, or submit a correction that was the same as the corrective action. • As such, we will review: • the difference between correction and corrective action • PRI Registrar’s expectations regarding correction and corrective action responses
NCR Responses • Definitions • Correction: action to eliminate a detected nonconformity • Corrective Action: action to eliminate the cause of a nonconformityand to prevent recurrence • Expectations • All NCR responses require both (separate) correction and corrective action. • Correction is always required, even if that just involves investigation into the extent of the issue.
Non-Applicable Clauses • Another two ANAB NCRs resulted from issues regarding clients’ non-applicable clauses: • The client had not identified N/A’s for each site in a multisite, and the auditor marked clauses in OASIS as N/A that had not been justified by the client. • If, while auditing, the auditor discovers a standard requirement that they cannot audit because it simply does not apply to the organization, and the client has not identified it as N/A or does not have a justification, a nonconformance shall be written. • Clauses were identified as N/A, but had weak or nonexistent justifications. • Any standard requirement identified as N/A must have a justification that includes at least a minimal level of detail as to why the N/A is justified.
Scopes • Several NCRs were related to inaccurate or misleading scopes of certification. • A full scope training presentation (for both auditors and clients) is being developed, but for now: • The scope statement must describe what the auditor is able to audit now, not what the client is planning on doing in the future. • E.g., if the company is not yet manufacturing, but plans to do so in the future, then unless they can present an accurate mock-up of their manufacturing process that meets requirements, then “manufacturing” cannot appear in their scope. • The scope must accurately reflect the activities for which they are being certified. • E.g., if a company’s scope lists a process or activity that cannot be validated during the audit, the auditor shall contact the PRI Registrar office to discuss revising the scope statement. • For non-single sites, the sub-scope for each site must clearly reflect the differences (or lack of difference) between the sites. NOTE: For the purposes of a scope statement, kitting does not qualify as manufacture unless kitting changes the actual material properties (e.g., metallurgical) of the product.
OASIS Functionality • Finally, several NCRs were written due to inaccurate data entered into the OASIS database. • One NCR was written against the inaccurate data itself. • Multiple NCRs were written (at least partially) based on other issues that were not truly problems, but looked like problems due to inaccurate data in OASIS. • Prior to submitting audit packages in OASIS, be sure to review your work for accuracy. In particular: • Ensure that N/A’s that are marked in Form 5 have corresponding justifications, and that the N/A’s in the QMS Matrix match. • Be sure that you are marking all relevant clauses that you audit, even if the requirement is met in a seemingly unrelated process. • Consider creating the PEARs before creating the QMS Matrix – this will make importing PEAR data into the Matrix easier. • Always remember to import the relevant site location on each form (including NCRs). • Make sure that processes audited at each site are properly marked on the QMS Matrix.