1. SAFETY MANAGEMENT SYSTEM Non Conformance Reporting
2009
CANADIAN COAST GUARD AUXILIARY - PACIFIC

2. Non Conformances / Observations
Used wherever an accident occurs to a person or a vessel, or a procedure in the Safety Management System is found not to work, or is not being followed.
They can be initiated by anyone, but would usually be a Coxswain, Station Leader, Manager, or internal or external auditor.

3. Non Conformances / Observations
Major Non Conformance – Issues where corrective action must be carried out immediately to meet the ISM Code, failure to do so would result in the withdrawal of the Safety Management Certificate and/or the Company Document of Compliance.

4. Non Conformances / Observations
Non Conformances – Issues where corrective action must be made to meet the ISM Code and/or ensure that the Procedures in the Safety Management System onboard are being followed correctly.
Time limited.

5. Non Conformances / Observations
Observations – Issues where improvements in the Safety Management System and procedures are recommended.
These do not have to be complied with, however they should be considered.

6. Handling of Non Conformances / Observations

7. Non Conformance System
In the following the Process Owner is the Manager responsible for the area of operation that went wrong in the accident.
e.g. The SAR Operations Manager is responsible for the Marine Operations Manual.
More than one Process Owner may be involved as well as the Executive Officer.

8. Non Conformance System 1
President
1. Non Conformance originated
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

9. Non Conformance System 2
President
President
2. Station Leader contacts Safety Manager with non conformance and suggested corrective action
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

10. Non Conformance System 3
President
3. Safety Manager assigns number and enters Non-Conformance Report into database.
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

11. Non Conformance System 4
President
4. Safety Manager copies Non-Conformance Report to appropriate Manager/ Process Owner.
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

12. Non Conformance System 5
President
5. Managers / Process Owner agree and decide on appropriate Corrective Action
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

13. Non Conformance System 6
President
6. Station informed of Corrective Action
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

14. Non Conformance System 74
Executive Officer
Safety Manager 3
Manager
(Process Owner)
Station
Leader 7
Coxswain
President 5 8 6 2 9
7. Corrective Action taken 1

15. Non Conformance System 8
President
8. Notification of Corrective Action taken, passed to Safety Manager
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

16. Non Conformance System 9
President
9. Non-Conformance closed out
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

17. Non Conformance System
The corrective action may consist of modification of:
1. the vessel or some vessels or equipment
2. the procedures covered by the Safety Management System
3. crew training practices or standards
4. reporting procedures ashore
5. the standard operating procedures at a station

18. Non Conformance System
………or some or all of the above

19. Non Conformance System
The accident and corrective action will be promulgated as necessary to Managers, President and the Board.
They may also be promulgated by use of the Lessons Learned section of the SAR Management System.

20. Non Conformance System
If the Safety Manager feels that there is insufficient support from managers for particular corrective action that he/ she deems necessary, the Safety Manager can go direct to the President with those concerns.

21. Scenario

22. Scenario
A dedicated rescue vessel is out on a training mission, and goes aground at speed, without damage.
It safely refloats, without damage, and returns to its berth.
The Coxswain will report the fact to the Station Leader.
All crew will write witness statements (preferably separately).

23. Scenario - Part 1 1. Non Conformance originated 4 President
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

24. Scenario - Part 1
Under the Safety Management System, the Station Leader will raise a Non Conformance Report.
This can be done initially by telephoning the Safety Manager, but will be followed up by a form in writing.

25. Scenario - Part 2
President
President
2. Station Leader contacts Safety Manager with non conformance and suggested corrective action
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

26. Scenario - Part 2
The Station Leader sends the written report plus statements as soon as possible to the Safety Manager.

27. Scenario - Part 3
President
3. Safety Manager assigns number and enters Non-Conformance Report into database.
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

28. Scenario - Part 3
The Safety Manager inspects the report and statements, and decides which manager (s) are responsible for possible corrective action e.g. SAR Operations and Training Managers, and also informs the Executive Officer
The Safety Manager will allocate a sequential number to the report, and enter summary of the non conformance in database.

29. Scenario - Part 3
It will be at this stage that the Safety Manager recommends to the Management Team that an investigation is to be carried out as soon as possible into all the circumstances of the grounding.
The Safety Manager shall lead this investigation.

30. Scenario - Part 4
President
4. Safety Manager copies Non-Conformance Report to appropriate Manager/ Process Owner.
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

31. Scenario - Part 4
The relevant information and results of the investigation will be sent to the appropriate members of the Management Team, which in this case will be the SAR Operations Manager and the Training Manager.

32. Scenario - Part 5
President
5. Managers / Process Owner agree and decide on appropriate Corrective Action
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

33. Scenario - Part 5
The Training Manager and the SAR Operations Manager will discuss departure from any procedures and the scope of the required corrective action.
The corrective action may include:
1. an appraisal of the the qualifications, sea-time and experience of all crew
2. a more rigorous maintenance requirement of electronic navigational aids

34. Scenario - Part 5
3. more of the designated crew to attend simulator training
4. compulsory use of certain navigational techniques
5. etc.
This corrective action is discussed with the Safety Manager, who has the final say.

35. Scenario - Part 6 6. Station informed of Corrective Action 4 President
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

36. Scenario - Part 6
The Safety Manager informs the station of the necessary corrective action, and co-ordinates any necessary outside assistance that may be needed.
It may be necessary for the appropriate manager to modify the written procedures and promulgate them.

37. Scenario - Part 7 7. Corrective Action taken 4 Executive Officer
Safety Manager 3
Manager
(Process Owner)
Station
Leader 7
Coxswain
President 5 8 6 2 9
7. Corrective Action taken 1

38. Scenario - Part 7
The Station Leader / managers take the agreed corrective action.

39. Scenario - Part 8
President
8. Notification of Corrective Action taken, passed to Safety Manager
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

40. Scenario - Part 8
The Station Leader / managers inform the Safety Manager of the completion of the required corrective action (crew reassessed, crew retrained, new procedures in place and all stations informed, ….)

41. Scenario - Part 9 9. Non-Conformance closed out 4 President
Executive Officer 4 5
Safety Manager
Manager
(Process Owner) 5 4 3 9 2 6 8 1
Station
Leader
Coxswain 7

42. Scenario - Part 9
The Safety Manager closes out the Non Conformance once he/ she is satisfied that the corrective action is completed, and informs the Station Leader.
In addition the Safety Manager can promulgate the sanitised details of the accident to the Lessons Learned section of the SAR Management System, and inform everyone of its existence.

43. Observations

44. Observations
In the case of say a Station Leader alerting the Safety Manager that a procedure in the Safety Management System is confusing or wrong, a similar process will take place (not involving the President, Executive Officer of Board) and can probably be closed out in two weeks or so.

45. Summary

46. Summary
The emphasis of this procedure is on continual improvement, and learning from mistakes.
The Safety Management System consists of living documents, which will change as the organisation grows and matures.