Corrective Action Review Plan


To define methods used in reporting a non-conformance, investigating the circumstances surrounding the occurrence of a non-conformance, recommending corrective actions, and reviewing the corrective action to ensure compliance with the Quality Plan.


This section describes the procedure for documenting Corrective Action.

Responsibility and Authority

Operations Manager and Administrative Manager shall have the responsibility and authority for the implementation of corrective action requirements for direct labor within their area of respective responsibility. They will monitor the Corrective Action Review process as written, see that corrective actions are documented and carried out, and implement (with approval of the President/CEO) any changes to training or work instructions. The Operations Manager and the Administrative Manager also craft preventive and corrective actions to prevent recurrence of non-conformance, monitor activities to determine effectiveness of measures, and identify when goals have been met.

The President/CEO shall have the responsibility and authority for reviewing these actions. The President/CEO meets monthly or more frequently as needed with Operations and Administrative Managers to oversee or monitor activities of the corrective action, review any and all information regarding possible solutions and make suggestions for possible solutions.

All employees responsible for meeting customer requirements shall have responsibility and authority to initiate corrective action.


The following non-conforming products/incidents will use the following forms:

  1. Customer complaint (Use Customer Contact Sheet);
  2. Quality Service Failure (ex: cleaning did not meet quality standards as identified by Supervisor or Operations manager, or three or more complaints involving one captain within one month – Use inspection list or Customer Worksheet);
  3. Safety Issue / Accident (see Safety & Health Manual);
  4. Breakage (use Broken Item Report);
  5. Any other error where determination of fault has been made.

A Corrective Action Review (CAR) form shall be initiated when it is determined that there has been an occurrence of a non-conforming product or incident that meets the following criteria:

  • Dollar amount of breakage is > $200.
  • Breakage results or has the potential to result in an insurance claim.
  • Incident results or has the potential to result in a lost customer.
  • Internal errors evident to the customer or resulting in inconvenience to the customer.

Any instance of a non-conforming product or incident will be reported by the individual discovering the non-conforming product or incident. If it meets above criteria, the Operations Manager or Administrative Manager will be notified verbally and a Customer Service Representative will complete a CAR form. The managers will prioritize the CAR according to seriousness, but all CARs must be acted upon within 5 business days.

The completed CAR form, with any recommendations or solutions, will be reported to the President/CEO for review. During the review, the President/CEO and the manager will determine:

  1. The correction to be initiated, and
  2. The preventive action to be instituted to prevent similar occurrences of non-conformance.

Corrective action shall be appropriate to the impact of the problems encountered. The Operations and Administrative Managers monitor the activities to determine the effectiveness of any corrective training performed or corrective action measures taken.

The Corrective Action Review (CAR) form includes the following necessary corrective action steps:

  • Non-Conforming Incident – A short statement that defines the incident or problem.
  • Facts Brought Out By the Investigation – List of all facts associated with the incident. Source of the facts should be included.
  • Root Cause(s) of Incident – List all possible causes of the incident uncovered during the investigation.
  • Possible Solutions – List all possible solutions that will prevent a reccurence of the incident.
  • Corrective Action(s) Taken – List any corrective actions taken in response to the incident.
  • Monitoring the Effectiveness of the Solution – List any controls that have been implemented to determine the effectiveness of solutions recommended for this incident.

NOTE: This process should be initiated within one business day of verbal notification of a non-conforming incidence. Once a plan of action is determined, a target closure date should be assigned.

The Operations Manager and the Administrative Manager are responsible for assuring that proper communication to the customer occurs on all corrective actions involving customers.