Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
4.1 General Requirements
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01. A QMS has been established, documented, implemented & maintained with evidence of continual effectiveness improvement. (CTS Quality Manual)
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03. The QMS addresses customer, statutory & regulatory requirements. (QM Sect 1 / 1.0)
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04. a) QMS processes have been determined & applied. (QM Sect v)
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05. b) Sequence & interaction determined for QMS processes. (QM Sect v)
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06. c) Crieria & methods determined to effectively operate & control QMS processes. (QM for criteria, QSP for methods)
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07. d) Availability of resources & information necessary to support the operation & monitoring available for QMS. (QM Sect 2 / 1.3.1.6)
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08. e) QMS processes are monitored, measured & analyzed. (QM Sect 2 / 1.8 and Sect 16)
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09. f) Actions implemented to continually improve planned results. (QM Sect 14 and Sect 1 / 5.4)
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10. Processes are managed in accordance with applicable AQMS standards. (AS9100 per QM Sect 1)
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11. Outsourced processes are defined & controlled. List outsourced processes.
4.2.1 General Documentation Req'ts
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12. a) Documented statement of a quality policy. (QM Sect ii, posters)
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13. a) Documented quality objectives. List quality objectives with goals.
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14. b) Documented quality manual. List QM revision.
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15. c) Documented procedures required by 9100 standard. (QSP 3-002 Document Control; QSP 12-001 Records; QSP 16-001 Audits; QSP 13-001 Nonconforming Parts; QSP 14-001 Corrective Action)
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16. c) Documented records required by 9100 standard. (Management Review, training, PO Review, vendor approval, process validation, calibration, audits, measurements, nonconforming parts, corrective/preventive actions)
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17. d) Necessary documents & records as per clause 4.2.1.d.
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19. Accessibility & awareness of personnel of relevant QMS documentation & changes.
4.2.2 Quality Manual
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20. A Quality Manual is established and maintained, and ...
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21. ... includes the scope of the QMS.
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22. ... includes justification of exclusions. List excluded clauses. (Design and Post-Delivery Servicing: QM Sect 19 and 20)
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23. ... includes QMS documented procedures or reference to them.
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24. ... includes a description of the QMS processes & interactions. (QM Sect v)
4.2.3 Control of Documents
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35. Documents required by the QMS are controlled.
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36. Records are controlled in accordance with clause 4.2.4.
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37. Documented procedure exists & includes the following: a) approval process (QSP 3-002 / 4.1)
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38. b) review, update & re-approval process (QSP 3-002 / 12.2)
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39. c) identification of changes & current revision status (QSP 3-002 / 12.3)
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40. d) documents are available where needed (QSP 3-002 / 12.7 and 12.8)
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41. e) documents are legible and identifiable (QSP 3-002 / 12.4)
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42. f) external documents are identified and controlled (QSP 3-002 / 12.6)
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43. g) obsolete documents are identified and controlled. (QSP 3-002 / 12.5)
4.2.4 Control of Records
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44. Records (as required in 4.2.4) are established & controlled.
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45. A documented procedure exists that includes controls for the following: -identification (QSP 12-001 / 4.1.2 and 4.2.1.1)
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46. -storage (QSP 12-001 / 4.0)
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47. -protection (QSP 12-001 / 4.0)
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48. -retrieval (QSP 12-001 / 2.3)
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49. -retention (QSP 12-001 / 3.0)
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50. -disposition (QSP 12-001 / 4.1.1 and 4.2.1.3)
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51. -records created &/or retained by suppliers (QSP 12-001 / 2.1.8 and CTS PO Spec)
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52. Records are legible, identifiable & retrievable. List samples of records reviewed.
5.1 Management Commitment
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56. Evidence of top management commitment includes the following: a) communicating the importance of meeting customer, statutory and regulatory requirements (QM Sect 2 / 1.3.1.2)
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57. b) establishing a quality policy (QM Sect ii)
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58. c) establishing quality objectives (QM Sect 1 / 5.8)
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59. d) conducting management reviews (QM Sect 2 / 1.6)
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60. e) ensuring availability of resources (QM Sect 2 / 1.3.1.6)
5.2 Customer Focus
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63. Top management ensures the following: -customer requirements are determined & met (QM Sect 2 / 1.3.1.2)
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64. -product conformity is measured (QM Sect 2 / 1.3.1.8)
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65. -on-time delivery performance is measured (OTD report)
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66. -actions are taken if planned results are not or will not be achieved
5.3 Quality Policy
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67. Top management ensures that the quality policy: a) is appropriate (QM Sect ii)
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68. b) includes a commitment to comply with requirements & continually improve the effectiveness of the QMS
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69. c) provides a framework to establish & review its quality objectives
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70. d) is communicated & understood
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71. e) is reviewed for suitability.
5.4.1 Planning: Quality Objectives
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72. Top management ensures that quality objectives are established. (QM Sect 1 / 5.8)
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73. Top management ensures that quality objectives are measurable. (QM Sect 1 / 5.8)
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74. Top management ensures that quality objectives are consistent with the quality policy. (QM Sect 1 / 5.8)
5.4.2 QMS Planning
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75. a) Top management ensures the QMS planning is carried out to meet the requirements defined in clause 4.1 & the quality objectives. (QM Sect 2 / 1.3.1.3)
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76. b) Top management ensures the QMS integrity is maintained when changes occur. (QM Sect 2 / 1.3.1.4)
5.5.1 Responsibility and Authority
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80. Top management ensures that responsibilities & authorities are defined. (QM Sect 2, job descriptions)
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81. Top management ensures that responsibilities & authorities are communicated. (QM on eDoc)
5.5.2 Management Representative
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84. Top management appointed Management Representative exists. (QM Sect 2 / 1.5, Quality Manager job description)
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85. Management Representative's responsibility & authority include: a) ensuring QMS processes are established, implemented & maintained. (QM Sect 2 / 1.5)
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86. b) reporting QMS performance (QM Sect 2 / 1.5)
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87. c) promoting customer requirements awareness (QM Sect 2 / 1.5 and 1.4.19)
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88. d) organizational freedom & unrestricted access to top management for resolution of quality management issues. (QM Sect 2 / 1.5 and 1.3.10)
5.5.3 Internal Communication
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90. Top management ensures communication processes are established & takes place on the effectiveness of the QMS.
5.6.1 Management Review: General
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91. Top management reviews the QMS for suitability, adequacy & effectiveness at planned intervals. (QM Sect 2 / 1.6)
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When was the last Management Review held?
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92. Management Review records are maintained. List Review records examined.
5.6.2 Management Review Input
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94. Inputs to Management Reviews include: a) audit results
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95. b) customer feedback
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96. c) process performance & product conformity
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97. d) preventive and corrective actions
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98. e) follow up actions from previous reviews
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99. f) changes that could possibly affect the QMS
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100. g) improvement recommendations.
5.6.3 Management Review Output
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104. Management Review outputs include: a) QMS process improvements
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105. b) customer requirement related product improvements
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106. c) identification of resource needs.
6.1 Provision of Resources
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112. Resources are determined & provided to: a) implement & maintain the QMS & improve its effectiveness (QM Sect 2 / 1.3.1.6 and QM Sect 15 / 1.0)
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113. Resources are determined & provided to b) enhance customer satisfaction (QM Sect 15 / 1.0)
6.2.1 Human Resources, General
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115. Personnel competency is based on education, training, skills & experience. (QSP 15-001, QM Sect 15)
6.2.2 Competence, Training and Awareness
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118. a) Competence for personnel affecting product quality is determined. (Job descriptions)
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119. b) Training to achieve competence is provided. (QSP 15-001)
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120. c) Evaluates effectiveness of actions taken.
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121. d) Ensures personnel are aware of the relevance & importance of their activities & contribution to realizing quality objectives.
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122. e) Maintains appropriate records per clause 6.2.2 requirements.
6.3 Infrastructure
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126. Determine, provide & maintain an infrastructure needed to achieve product conformity including: a) buildings, workspace & associated utilities
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127. b) process equipment
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128. c) supporting services.
6.4 Work Environment
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130. Determine & manage the work environment needed to achieve product conformity.
7.1 Planning of Product Realization
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131. Plan & develop consistent product realization processes. (QSP 5-001)
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132. Product realization planning reflects the following: a) quality objectives & product requirements
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133. b) processes, documents & resources
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134. c) verification, validation, monitoring, measurement, inspection & test activities (QSP 8-001)
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135. d) records
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136. e) product configuration (QSP 15-001 / Purpose)
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137. f) resources.
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138. Planning is in a suitable form for the organization's operations.
7.1.1 Project Management
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141. Product realization is planned & managed in a structured & controlled manner to meet requirements at acceptable risk. (QSP 5-001 / Purpose)
7.1.2 Risk
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142. Establish, implement & maintain a process for managing risk. (QSP 1-002)
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143. Risk management includes, as appropriate to the organization & product: a) responsibilities for risk management (QSP 1-002 / 1.1)
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144. b) definition of risk criteria (QSP 1-002 / 2.0)
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145. c) identification, assessment & communication of risks (QSP 1-002 / 3.1)
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146. d) identification, implementation & management of actions to mitigate risks that exceed risk acceptance (QSP 1-002 / 4.0)
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147. e) acceptance of remaining risks after implementation of mitigating actions. (QSP 1-002 / 5.0)
7.1.3 Configuration Management
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148. Establish, implement & maintain a configuration management process that includes, as appropriate to the product: (QSP 1-003)
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149. a) configuration management planning (QSP 1-003)
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150. b) configuration identification (QSP 1-003 / 3)
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151. c) change controls (QSP 1-003 / 4)
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152. d) configuration status accounting (QSP 1-003 / 5)
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153. e) configuration audits. (QSP 1-003 / 6)
7.1.4 Control of Work Transfers
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154. Establish, implement & maintain a process to plan & control work transfers including: (QSP 6-001 / 4.3)
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155. - temporary or permanent transfers
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156. - verification of work conformity to requirements.
7.2.1 Determination of Requirements Related to the Product
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157. a) Determine customer requirements, including delivery & post-delivery activities. (QSP 4-001 and QSP 4-002 / 10)
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158. b) Determine requirements not stated by the customer,but necessary for specified or intended use. (QSP 5-001 / 2.0)
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159. c) Determine applicable statutory & regulatory requirements. (QSP 5-001 / 2.0)
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160. d) Determine any additional necessary requirements. (QSP 5-001 / 2.0)
7.2.2 Review of Requirements Related to the Product
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161. Reviews product requirements prior to commitment to supply a product. (QSP 4-001, QSP 4-002, QSP 5-001)
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162. Reviews conducted to the customer documentation to ensure: a) product requirements are defined (QSP 4-001 / 2.2 and QSP 4-002 / 2.3.1)
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163. b) differing contract requirements are resolved (QSP 4-002 / 2.3.3)
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164. c) organization has the ability to meet the requirements
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166. d) special product requirements are determined
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167. e) risks have been identified (QSP 4-002)
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168. Records of reviews & actions are maintained. List records examined.
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169. Where the customer provides no documented requirements they are confirmed before acceptance. (QSP 5-001 / 1.0)
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170. Documents are amended & personnel made aware when product requirements are changed. (QSP 4-002 and QSP 5-001)
7.2.3 Customer Communication
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172. Implements effective customer communications for: a) product information (QSP 13-001 and QSP 5-006)
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173. b) enquiries, contracts or order handling (QSP 4-001 and QSP 5-006)
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174. c) customer feedback. (QSP 14-002)
7.3 Design - justified exclusion
7.4 Purchasing Process
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219. Purchased product conforms to specified requirements. (QSP 6-001)
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220. Responsibility evident for product conformity for all purchased products (including product from customer directed suppliers). (QSP 6-001 / 2.1)
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223. Criteria for selection, evaluation & re-evaluation of suppliers are established. (QSP 6-001 / 2.8.2 & 2.8.3)
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224. Records of evaluations & actions arising from the evaluations are maintained. (QSP 6-001 / 2.8.2.1)
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225. a) Register of approved suppliers including scope of approval is available. (QSP 6-001 / 2.2 and Approved Vendor List)
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226. b) Supplier performance is periodically reviewed. (QSP 6-001 / 2.8)
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227. c) Process for dealing with suppliers that do not meet requirements is defined. (QSP 6-001 / 2.8.3)
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228. d) The organization & all suppliers use customer-approved special process sources. (QSP 6-001 / 2.6)
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229. e) The process, responsibilities & authority for the approval status decision, changes & conditions for controlled use are determined. (QSP 6-001 / 2.8.3.3 & 2.8.2.1)
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230. f) The risk when selecting & using suppliers is determined & being managed. (QSP 1-002 / 4.3)
7.4.2 Purchasing Information
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233. Purchasing in formation includes (where appropriate): a) product, procedures, processes & equipment approvals (QSP 6-001 / 3.1.1)
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234. b) personnel qualifications (QSP 6-001 / 3.1.2)
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235. c) QMS requirements (QSP 6-001 / 3.1.3 and CTS PO Spec 1.1)
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236. d) revision status relevant technical data (QSP 6-001 / 3.1.4 and CTS PO Spec 2.2)
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237. e) requirements for design, test, inspection, verification, use of statistical techniques & related instructions for acceptance (including critical items & key characteristics) (QSP 6-001 / 3.1.5)
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238. f) requirements for test specimens (QSP 6-001 / 3.1.6)
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239. g) requirements for suppliers to notify of nonconforming product; receive nonconforming product disposition approvals; notify of changes to product, processes, suppliers & facilities; and flow down requirements (QSP 6-001 / 3.1.7 - 3.1.9 and CTS PO Spec 2.1 & 1.5)
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240. h) records retention requirements (CTS PO Spec 2.3)
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241. i) right of access (QSP 6-001 / 3.1.11 and CTS PO Spec 4.0)
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246. Adequacy of purchase requirements prior to issuance. (QSP 6-001 3.4 and QSP 6-005)
7.4.3 Verification of Purchased Product
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247. Activities to ensure purchased product meets purchase requirements have been established & implemented. (QSO 5-009 and QSP 6-001 4)
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248. A process of product recall is implemented when product is released for use prior to completion of required incoming verification. (QSP 6-001 / 4.1)
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249. Requirements for supplier delegations are defined & a register of delegations is maintained. (N/A for CTS)
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250. Purchasing information defines information about the verification activities at the supplier's premises. (N/A for CTS)
7.5.1 Control of Production & Service Provision
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251. Production & service provisions are planned & achieved under controlled conditions including: (QSP 5-001 and QSP 5-006)
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252. a) availability of product characteristics
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253. b) availability of necessary work instructions
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254. c) use of suitable equipment
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255. d) Availability & use of monitoring & measurement (M&M) equipment.
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256. e) implementation of monitoring & measurement
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257. f) implementation of product releases, delivery & post-delivery (QSP 5-006, QSP 7-001, QSP 8-001 - delivery & post-delivery not applicable to CTS)
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258. g) accountability for all product during production (routers)
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259. h) evidence that all operations have been completed as planned (QSP 5-006 / 5.3, routers)
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260. i) provisions for a Foreign Object Debris/Damage (FOD) program (QSP 5-022)
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261. j) monitoring & control of utilities & supplies (QSP 5-001 / 3.0)
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262. k) criteria for workmanship (QSP 5-001 /3.4)
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267. Planning appropriately considers: - managing critical items & key characteristics (QSP 5-001 / 3.0 and 3.4)
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268. - measurement tooling (QSP 5-001 / 3.0 and 3.4)
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269. - identifying in-process verification points (QSP 5-001 / 3.0 and 3.4)
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270. - special processes (thermal spray, paint, dry film lube, shot peen are special processes used by CTS)
7.5.1.1 Production Process Verification
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271. A representative item from the 1st production run is used to verify production processes, documentation & tooling and is capable of producing parts & assemblies that meet requirements. (QSP 5-006 / 11)
7.5.1.2 Control of Production Process Changes
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273. Personnel authorized to approve changes are defined. (QSP 5-001 / 7.0)
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274. Changes affecting processes, equipment, tools or software are controlled & documented.
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275. Changes are assessed to confirm that product conformity has not been adversely affected. (QSP 5-001 / 11.0)
7.5.1.3 Control of Production Equipment, Tools and Software
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276. Production equipment, tools & software used to automate, control or monitor processes are validated prior to release for production & are maintained.
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279. Storage requirements are defined for production equipment or tooling.
7.5.1.4 Post-Delivery Support - justified exclusion
7.5.2 Validation of Processes for Production and Service Provision
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285. Special processes are validated prior to use. (VSE, source substantiation)
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286. Special process validations demonstrate the ability to achieve planned results.
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287. Established arrangements include, as applicable: a) criteria for review & approval
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288. b) approval of equipment & qualification or personnel (QSP 3-001 and QSP 3-005)
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289. c) use of specific methods & procedures
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290. d) requirements for records (QSP 12-001)
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291. e) revalidation.
7.5.3 Identification and Traceability
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292. Products are identified throughout product realization. (QSP 5-006 - routers)
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293. Product configuration is maintained. (QSP 1-003)
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294. Product status is identified throughout product realization. (routers, nonconformance tags)
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295. Controls are in place for media used for acceptance. (Q-067 Stamp Log)
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296. When required traceability is controlled through unique product identifications & records are maintained.
7.5.4 Customer Property
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298. Customer property is adequately controlled through identification, verification, protection & safeguarding.
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299. Lost, damaged or product unsuitable for use is reported to the customer & records maintained. (QSP 13-001)
7.5.5 Preservation of Product
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301. Products are preserved during internal processing & delivery. (QSP 7-001)
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302. Preservation includes identification, handling, packaging, storage & protection. (QSP 7-001)
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303. Preservation controls are applied to the constituent parts.
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305. Preservation of product includes, as appropriate, a) cleaning (QSP 5-003)
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306. b) foreign object controls (QSP 5-022)
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307. c) special handling for sensitive products (N/A for CTS)
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308. d) marking & labeling (N/A for CTS)
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309. e) shelf life control & stock rotation (QSP 5-010)
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310. f) special handling for hazardous materials (N/A for CTS for product)
7.6 Control of Monitoring and Measuring (M&M) Equipment
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312. Product M&M and appropriate M&M equipment have been determined. (QSP 10-001)
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313. A register of the M&M equipment is maintained. (GagePack software)
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314. Processes are defined for M&M equipment calibration (&/or verification), including equipment type, identification, location, frequency, check method & acceptance criteria. (QSP 10-001, "Q" procedures)
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315. M&M can be and are carried out consistent with the M&M requirements.
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316. Environmental conditions are suitable for the calibrations, inspections, measurements & testing being carried out. (QSP 10-001 / 4.2)
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317. a) M&M equipment are calibrated (&/or verified) at specified intervals against traceable standards. (QSP 10-001 / 1.2 & 1.0)
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318. b) M&M equipment are adjusted when necessary. (QSP 10-001 / 4.3)
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319. c) M&M equipment have unique identifiers. (QSP 10-001 / 2.2 & 4.6)
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320. d) M&M equipment are safeguarded from adjustments (QSP 10-001 / 1.0)
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321. e) M&M equipment are adequately protected.
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322. A M&M equipment calibration (&/or verification) recall process exists. (QSP 10-001)
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323. Previous results are assessed, recorded and acted upon when M&M equipment is found to be out of conformance. (QSP 10-001 / 11.0)
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324. Calibration (&/or verification) records are retained. (QSP 12-001)
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325. Software used for M&M is confirmed before initial use & reconfirmed as necessary. (QSP 10-001 / 4.8)
8.1 General Measurement, Analysis and Improvement
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327. Monitoring, measurement, analysis & improvement processes are planned & implemented to a) demonstrate product conformity
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328. b) ensure QMS conformity
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329. c) improve QMS effectiveness
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330. Applicable methods (including statistical techniques) have been determined & are being used. List examples of methods:
8.2.1 Customer Satisfaction
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331. Methods for obtaining/using customer perception data are in place. (QSP 4-003)
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332. Customer satisfaction information includes product conformity, on-time delivery, customer complaints & corrective action requests.
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333. Improvement plans to address customer satisfaction deficiencies are in place.
8.2.2 Internal Audit
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334. Internal audits are conducted at planned intervals. (QSP 16-001 / 2.0)
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335. a) Audits ensure conformity to planned arrangements, requirements of the AS9100 standard & the organization's QMS requirements. (QSP 16-001 / 1.1 & 1.2)
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336. b) Audits ensure the QMS is effectively implemented & maintained. (QSP 16-001 / Purpose)
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337. Audits are based on the status & importance of processes & previous audit results to defined criteria, scope, frequency & methods. (QSP 16-001 / 2.4)
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338. Auditors do not audit their own work. (QSP 16-001 / 3.2)
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339. A documented internal audit procedure exists. (QSP 16-001)
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340. Audit records are maintained. (QSP 16-001 / 4.4)
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341. Timely corrective actions are taken by management in audited areas. (QSP 16-001 / 4.2)
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342. Follow-up activities verify & report actions taken. (QSP 14-001 / 6.0)
8.2.3 Monitoring and Measurement (M&M) of Processes
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343. Methods for M&M of QMS processes are in place & demonstrate that the processes achieve planned results.
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344. Correction & corrective actions are taken when results are not achieved.
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345. Process nonconformities result in: a) actions to correct the nonconforming process (QSP 13-001 / 2.2.3)
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346. b) evaluation of the effect on products (QSP 14-001 / 2.7)
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347. c) determination of the effect on other processes or products (QSP 14-001 / 2.7)
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348. d) control of nonconforming product. (QSP 13-001)
8.2.4 Monitoring and Measurement (M&M) of Product
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349. M&M of product characteristics are performed & maintained. (QSP 8-001)
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351. Acceptance measurement requirements are documented and include: (technical plans & routers)
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352. a) acceptance &or rejection criteria
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353. b) the sequence where measurement & testing operations are planned
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354. c) records of measurement results
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355. d) specific measurement instruments required
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357. Critical items are controlled & monitored. (QSP 5-001 / 3.0)
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358. Sampling plans are justified on the basis of recognized statistical principles & appropriate for use.
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360. Product released for use prior to the completion of planned activities is controlled to allow for recall. (QSP 5-006 / 8.2)
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361. Records reflect the person(s) authorizing the release of product for delivery.
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362. Records show that products meet defined requirements.
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363. Release of product &/or delivery of services are not performed until all planned activities are accomplished or without authority/customer approval. (QSP 5-006 / 8.2)
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364. Documents required to accompany the product are present at delivery. (QSP 5-006)
8.3 Control of Nonconforming Product (NCP)
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369. NCP is identified & controlled.
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370. A documented procedure exists for handling of NCP. (QSP 13-001)
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371. The responsibility & authority for the review & disposition of NCP are defined. (QSP 13-001 / 1.1)
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372. The process for approving personnel making these decisions is defined. (QSP 13-001 / 2.2.6 & 2.2.7)
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373. NCP controls include: a) actions to eliminate the nonconformity (QSP 13-001 / 2.2.3)
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374. b) use, release or acceptance by customer concession (QSP 13-001 / 2.2.1 & 4.1)
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375. c) actions to preclude its intended use or application (QSP 13-001 2.1)
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376. d) actions on the effects of NCP, when detected after delivery or use, including timely reporting (QSP 13-001 / 3.4)
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377. e) actions to contain the nonconformity effect on other process or products. (QSP 14-001 / 2.7)
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378. Dispositions of use-as-is or repair is used only after approval from design responsible organization. (QSP 13-001 / 4.1)
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379. Dispositions of use-as-is or repair are not used without customer authorization. (QSP 13-001 / 4.1)
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380. Scrap product is marked or positively controlled. (QSP 13-001 / 2.2.4)
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381. Corrected NCP is re-verified. (QSP 5-011 / 3.1)
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382. NCP records are maintained. (QSP 12-001)
8.4 Analysis of Data
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383. Data to demonstrate the suitability & effectiveness of the QMS is determined, collected & analyzed.
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384. Analysis of data includes customer satisfaction.
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385. Analysis of data includes conformity to product requirements.
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386. Analysis of data includes characteristics & trends of processes & products.
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387. Analysis of data includes supplier performance.
8.5.1 Continual Improvement
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389. The QMS is continually improved trough the quality policy, quality objectives, audit results, analysis of data, corrective/preventive actions and management review.
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390. Improvements & the evaluation of effectiveness are monitored.
8.5.2 Corrective Action
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391. Actions are taken to eliminate the causes of nonconformities.
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392. A documented procedure exists that includes: (QSP 14-001)
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393. a) reviewing of nonconformities (QSP 13-001 / 1.1)
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394. b) determining the causes of nonconformities (QSP 14-001 / 2.6)
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395. c) evaluating action to prevent recurrence (QSP 14-001 / 2.8)
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396. d) determining & implementing actions (QSP 14-001 / 2.8)
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397. e) record of actions taken
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398. f) reviewing the effectiveness of corrective action (QSP 14-001 / 6.0)
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399. g) flowing down corrective action requirements to suppliers (QSP 14-001 / 2.4 and CTS PO Spec)
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400. h) actions where timely &or effective corrective actions are not achieved (QSP 14-001 / 2.7)
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401. j) determining if additional nonconforming product exists. (QSP 14-001 / 2.7)
8.5.3 Preventive Action
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403. Actions are taken to eliminate the causes of potential nonconformities.
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404. A documented procedure exists that includes: (QSP 14-001)
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405. a) determining potential nonconformities & their causes (QSP 14-001 / 5.1)
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406. b) evaluating action to prevent occurrence (QSP 14-001 / 2.8)
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407. c) determining & implementing action (QSP 14-001 / 2.8)
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408. d) record of actions taken
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409. e) reviewing the effectiveness of preventive action (QSP 14-001 / 6.0)