QUALITY MANAGEMENT SYSTEM

Transcription

1 QUALITY MANAGEMENT SYSTEM 1. Introduction Chapter As part of its mandate, the UNMAO, as the appointed representative of the NMAO and the SSDC, is required to ensure that the standards of humanitarian demining activities and the processes and procedures implemented whilst conducting them are in accordance with IMAS, SudanMAP NTSG s, mine action organisations own SOP and/or implementation plans and any other agreements, contracts or memorandums of understanding that are in place between the authoritative bodies and said mine action organisations. 1.2 This will be achieved through the appointment of a monitoring body responsible for the programmes overall Quality Management (QM) system and the implementation of a comprehensive and robust QM system, developed by the UNMAO and to be adhered to and implemented by all mine action organisations. 2. General Principles, Implementation and Conduct of the QM System 2.1 The QM system is designed to coordinate activities aimed at directing and controlling the UNMAO quality processes and procedures. The overall objective is to provide the authoritative bodies and donors with the confidence and assurance that mine action organisations have applied and adhered to standards that are in accordance with IMAS, NTSG and their own SOPs by applying safe, effective and efficient humanitarian demining processes and procedures during the conduct of operations for which they are contracted. 2.2 The system comprises of internal and external QA processes and procedures carried out prior to the commencement of and during humanitarian demining activities and followed by external QC processes when practicable on the completion of activities. 2.3 To achieve this, the system will scrutinise all aspects of a mine action organisation s capabilities (people, equipment and procedures), processes and procedures prior to, during and on completion of humanitarian demining activities. 2.4 The complete system process comprises of the following: a. Accreditation: This is the overall process of determining an organisation s suitability, competency and ability to plan, manage and operationally conduct humanitarian demining activities safely, effectively and efficiently. For all information and detail concerning the accreditation process within SudanMAP see Chapter 21. Page 1 of 9

2 b. Monitoring: Internal and external QA processes shall be implemented and adhered to as follows: (1) Internal Monitoring: Each mine action organisation will be required to implement the QM system across the complete spectrum of their operations by using the current quality assurance forms contained within the IMSMA database. During this the mine action organisations at ground level i.e. on site, shall be required to conform to the prescribed procedure involving the observation and examination of relevant humanitarian demining activities and the recording of these observations in an approved and agreed format, i.e. relevant IMSMA QA forms, thus providing sufficient mechanisms that allow internal QA to be conducted in a transparent manner. (2) External Monitoring: Regular external monitoring visits will be conducted aimed at examining as wide a range of relevant activities as possible. To achieve this, visits will audit the internal monitoring of the mine action organisation, conduct QA checks and assessments of the mine action organisations activities, processes and practices and examine the level of knowledge and competency of the mine action organisation, by questioning key individuals on site,. c. Quality Management and Auditing of the Monitoring Processes: Overall quality management will be provided by a Quality Management Body. This will in the main be in the form of an appraisal of post-visit reports, an assessment of corrective advice given and actions taken and where possible and practicable the accompanying of the External Monitoring QA Officer by a member of this body during visits. 3. QM System Bodies - General Responsibilities 3.1 The UNMAO shall appoint and accredit the following: a. External Monitoring Body: This body will be responsible for externally monitoring the mine action organisation and for ensuring that the degree to which inherent characteristics fulfils requirements. It will comprise of: (1) Regional Quality Assurance Officer primary responsibility for coordinating the QA monitoring programme (2) UNMAO sub-office Quality Assurance Officer primary responsibility for conducting external monitoring (3) UNMAO sub-office Operations Officer and specialists support and assist external monitoring process as requested. b. Quality Management Body: This body will be responsible for the quality management of the monitoring process and auditing the UNMAO external monitoring QA system. It will comprise of the following: (1) National Quality Assurance Coordinator primary responsibility for coordinating and ensuring the integrity of the QM process (2) Regional Quality Assurance Officer conduct audit of the external monitoring process when requested to ensure integrity of the QM system. Page 2 of 9

3 (3) Regional Operations Coordinator support and assist as requested 3.2 Mine action organisations shall ensure that sufficient and suitable resources are appointed in order to implement the required internal monitoring system at each task site so as to adhere to and instigate the required QM system as prescribed. This is due to it being an integral part of effective command, control and supervisory procedures, within the organisation. The internal QA management policy shall be included into the mine action organisations SOP s and should be adhered to during operations. 4. SPECIFIC RESPONSIBILITIES 4.1 Internal Monitoring Body: The internal monitoring body has the following specific responsibilities: a. Conduct daily QA of the current operational tasks in accordance with the organisational SOPs. a. Complete a complete set of IMSMA QA forms relevant to the task (see Annex A) for every 36-working days or part thereof that the task lasts b. Accurately record the results of the monitoring conducted on the relevant form ensuring all critical and non-critical non-conformities are clearly recorded. c. If a critical non-conformity is identified then work is to cease immediately and the UNMAO sub-office QA officer is to be contacted in order to confirm the non-conformity and to advise on the suitability of the rectifying action in accordance with the relevant NTSG. d. Store hard copies and electronic copies of the IMSMA QA forms on site and make them available for the external monitoring body e. Upload completed IMSMA forms into the IMSMA data base. f. Ensure appropriate follow-up action is implemented and adhered to following external monitoring body s recommendations. 4.2 External Monitoring Body: The external monitoring body comprising of one individual or the complete body should aim to visit all tasks sites within their area of operation as often as practicably possible. Visits shall be coordinated to occur at the beginning of the task, during the task (frequency will depend on duration) and during the completion survey. As a minimum the following requirements are to be implemented and adhered to: a. On each Monday the body, specifically the sub-office QA officer, is to provide an external monitoring plan for the next week (Monday Friday in the South, Sunday to Thursday in the North) and a summary based on the previous weeks external monitoring activities, to the National QA Coordinator. This is to conform to the formats and details at Annex B. Page 3 of 9

4 b. It is acknowledged that due to a number of factors, including but not restricted to logistical constraints, communication and travel difficulties, the duration of individual tasks i.e. EOD spot tasks, and the general difficulties encountered whilst moving around Sudan in a timely and efficient manner, it will not always be possible and/or practicable to adhere to the following visit schedule. However, whenever possible and/or practicable external monitoring visits are to meet the following requirements: i. If the task is of less than 3-days duration once within this 3-days. ii. For tasks of greater than 3-days but less than 15-days duration once within the first 3-days and once within 3-days prior to the completion of the task. iii. For tasks of between 15-days and 36-days duration once within the first 3-days, once during the lifetime of the task and once within 3-days prior to completion of the task. iv. For tasks of greater duration than 36-days, once within the first 3- days and, once between the 15-day and 36-days point and then subsequent visits of not more than 15-days gap or 3-days prior to completion of the task whichever is lesser. Deviation from this schedule is not to be the norm and should only apply in extreme circumstances. In all cases it is to be authorised by the Regional QA officer, or in his absence the Regional Operations Coordinator, who is to inform the National QA Officer. c. When tasks are not visited due to the aforementioned circumstances then mine action organisations should be requested to submit the relevant completed IMSMA forms in electronic format within 3-days of the task being completed. d. During every visit the external monitoring body shall: i. Conduct a QA inspection of at least one specific activity, completing the relevant IMSMA QA forms and submitting it via IMSMA. The details of this completed form are to be compared against any of the most recent same forms completed during internal monitoring for accurateness. As a minimum the IMSMA form External QA Inspection is to be completed. When completing this form the amount of different IMSMA forms and the relevant number of results i.e. high/medium/low completed by the internal monitoring body is to be recorded. ii. Identify any non-conformity and take appropriate action depending on the circumstances and severity of the non-conformity, iii. Identify and suggest corrective actions to the mine action organisation and ensure they are implemented by agreeing and implementing a follow up plan. iv. Record all non-conformities and the general results of the visit. e. During the completion survey or at every 36-day point of a task (whichever is lesser) the external monitoring body shall visit the task site and: Page 4 of 9

5 Page 5 of 9 Chapter 14 i. Inspect and examine all of the mine action organisations internal QA records completed since the last visit recorded and/or covered by postvisit QA report to ensure compliance with procedures and sign off the forms as a record of compliance. ii. Conduct an overall on-site inspection of on-going activities in order to compare them against the internal QA records. iii. Conduct impromptu and/or unplanned questioning of the mine action organisations on-site representative based on the on-site inspection and based on issues that may cause concern, are not accurately reflected in the internal QA records or that need explaining/confirming. iv. Conduct pre-planned questioning of the mine action organisations on-site representative from a prescribed question bank which will require detailed explanations and/or responses on processes and procedures relevant to the organisations SOPs and NTSG aimed at determining the knowledge and competency of the mine action organisations on-site representative and the ability to comply and implement the detail of said documents. Be prepared to question further on specific issues until objective evidence is ascertained in order to provide a conclusion to findings or non-conformities. v. Draft a post-visit QA report detailing all aspects of the visit and including all other relevant documentation. The report will follow the minimum format at Annex C and this is to be submitted to the Quality Management Body and the relevant mine action organisation within 10- days of the visit. f. For any task that is completed conduct a visit in order to fill out an IMSMA Completion Form and Report. g. Ensure appropriate follow-up action is taken on the Quality Management Bodys recommendations. 4.3 Quality Management Body: The specific responsibilities of the individuals and/or the body as a whole are to: a. Ensure compliance with the QM system at all levels by reviewing the post-visit reports. b. Accompany the external monitoring body when ever possible or practicable to ensure general standards and the details of this chapter are being adhered to and met. c. Identify shortcomings in individual QA skills, overall practices, nonconformities with the system at any level and improvements to the system. d. Identify and suggest corrective actions to the external monitoring body and ensure they are implemented e. Develop and keep a database in order to identify trends of performance by teams/mine action organisations, 5. Overall General Responsibilities 5.1 The following overall general responsibilities shall apply:

6 Page 6 of 9 Chapter 14 a. Mine action organisations shall provide relevant bodies access to all sites, personnel, buildings and other facilities which need to be visited in order to implement any stage of the QM system. b. QM system bodies shall make available applicable documentation concerning on site visits and inspections as required to the authoritative bodies, to the mine action organisations and to other authorised bodies. c. An electronic version of the post-visit QA report will be filed by the National QA Coordinator on the UNMAO server Company Main Folder. A hard copy is to be stored at the relevant UNMAO sub-office. d. The responsible QA monitoring body shall prepare and maintain records of all site visits, and any information needed to understand and interpret them. All records shall be safely stored for a period of at least five years, held secure and in confidence to the applicant, unless otherwise required by law. e. All bodies as a whole and as individuals are to ensure they are fully aware of all aspects of the mine action organisations activities relevant to the purpose of the visit. This should include: i. All relevant documentation including contracts, accreditation documents, clearance plans and or implementation plans. ii. Accredited SOP s. iii. Reports from previous QA monitoring visits of the task and/or of the team and/or of the site as relevant. iv. The results of post-clearance inspections, accident / incident Investigation reports. v. All other information which will assist the body develop a plan and programme for its site visit. 6. Conduct during QA Visits 6.1 When a body arrives at a task site the UNMAO representative will report to the Control Point and introduce himself to the person in charge of the task and state the purpose of their visit. The following guidelines should then be followed: a. All safety instructions are adhered to. b. The body should be firm, polite and objective in their judgement. They should remain impartial at all times and not let personal opinions; family ties or friendships affect their judgement and performance of their duties. c. The body are not to make general commitments to any individual or organisation on behalf of the NMAO. d. The body are not to make changes to techniques taught on the organisations training courses or to procedures detailed in their SOP s. The body should only annotate recommendations or changes in QA Reports for possible subsequent further action. e. Any concerns or any suggestions concerning the mine action organisations activities are to be noted the attention of the Quality Management Body in a timely and appropriate fashion. f. The body are not to get involved in any argument with any member of the mine action organisation during or after a visit. If a heated situation does

7 develop the body is to leave the site and report the incident to the QA Audit Body. g. Serious negative concerns from the report should be discussed with the Audit Body as soon as possible after returning from the visit especially where safety aspects and are concerned. h. In certain circumstances where the body considers the demining organisation to be in serious breach of the organisation SOP s, NTSG s or IMAS, the United Nations Regional or National Mine Action Office may authorise the immediate suspension of specific demining operations. i. When closing or suspending a site the body must strictly adhere to the laid down procedure in this NTSG s. j. At all times objective evidence is to be used to base decisions on. Observations maybe made based on experience of the QA Body however it is to be noted that it is an observation only. k. The results of the QA visits are to be discussed with the mine action organisation supervisor, team leader or project manager prior to departure from the site, drawing attention to any major concerns, particularly those involving safety. These personnel should also make their own views known by writing their points on the relevant QA evaluation form or to be attached to the post-visit QA report. l. On completion of the visit any completed and signed QA evaluation form will be submitted as per normal procedures. m. On completion of this information transfer the original QA evaluation form will be stamped, signed and placed in archives. 7. Critical & Non-critical Non-conformities 7.1 General: During monitoring visits the body may identify non-compliances with SOPs/NTSGs. All instances of non-conformities shall be appropriately recorded as previously described in this chapter. The circumstances and/or severity of non-conformities will determine the subsequent actions taken. The following paragraphs provide guidance on non-compliances. 7.2 Non-critical Non-conformities: Non-critical non-conformities can generally be defined, but should not be restricted to: a. Breaches of SOPs that ARE NOT considered as life threatening and/or:- b. Breaches of SOPs that can be rectified immediately without further training or additional resources being required/deployed. 7.3 Critical Non-conformities: A critical non-conformities can generally be defined as breaches of SOPs THAT ARE considered to be life threatening. The following list, although not exhaustive, gives examples of critical non-conformities: a. When the prescribed communication network is not fully functioning. b. When there is no medical support in accordance with the organisation s SOP and/or NTSG. c. When there is insufficient or incorrect marking of hazardous areas where activities are being conducted. Page 7 of 9

8 d. When any personnel are not wearing prescribed PPE within the hazardous area during operations. e. Where there is inadequate supervision in accordance to the clearance organisation s SOP. 7.4 There may be occasions when non-conformities outside of the scope of SOPs may occur. The following list, although not exhaustive, provides examples of such non-conformities that may be recorded: a. The repeated failure to apply accredited management systems b. Refusal to allow monitoring or inspection to take place c. Interference with monitoring or inspections d. The premature release of cleared land e. Application of processes known to place staff or the local population at unacceptable risk. 8. Suspension of Tasks 8.1 During monitoring there may be cause to suspend tasks for safety reasons. The following list, although not exhaustive, gives examples when the relevant body may suspend a task on behalf of the UNMAO: a. Where a number of non-critical non-conformities are observed that either individually or as a whole either cannot be adequately and effectively rectified immediately or that as whole constitute a threat to life. b. Where a critical non-conformity has been identified. c. Where there is a current or imminent threat from external factions to the security and safety of the body, mine action organisation or other personnel. d. When there is any encroachment into hazardous areas that cannot be resolved. e. Where there is a reoccurrence of non-critical non-conformity(ies) within a team identified during separate visits. f. As a result of a demining accident/incident (refer to Chapter 15). 8.2 Following the suspension of any task, the Quality Management Body is to be immediately informed. All relevant information is to be clearly and appropriately recorded. Only when the issues have been resolved/rectified and only on the authorisation of the Quality Management Body are suspended tasks allowed to become operational again. 8.3 The suspension of a task may result in the suspension or termination of operational accreditation, (refer to Chapter 21, paragraph 6). 9. Special QA Monitoring 9.1 Special QA Monitoring will be conducted by the QA Management Body. Page 8 of 9

9 9.2 Special QA Monitoring aims to identify and confirm that problems, nonconformities and/or other such issues have been resolved. Such inspections are to be conducted in an open manner in consultation with the management of the particular clearance organisation. The Quality Management Body must ensure objectivity and impartiality of conducting Special QA Monitoring evaluations. 9.3 If, after conducting QA Special Monitoring on at least two separate occasions, identified concerns have not been resolved, the Quality Management Body in consultation with the Chief of Operations Officer will review the accreditation licence. 9.4 It must be appropriately and clearly annotated that Special QA Monitoring is being conducted on the particular asset in question. 9.5 The following are examples of circumstances when special monitoring may be required: a. After the suspension of a task as described in paragraph 8. b. Starting a task in an unfamiliar area. c. Working on a difficult or hazardous task (e.g., undulating ground, rocky, highly vegetated, residential, trip-wires and improvised mines). d. A change in supervisory personnel or when inexperienced personnel are managing a task. e. Handover to national staff as part of the capacity building process. f. Commencing operations after a lengthy period away from operations or after completing a training course. g. Introduction of new demining procedures or equipment. h. Conducting field trials with equipment and machines. i. Multiple assets working at a task. 10. Summary 10.1 The SudanMAP QM system has been deigned to ensure that an appropriate, suitable and sufficient QA monitoring process, that consists of regular monitoring visits and auditable processes at all stages of operations is implemented. If implemented correctly at all levels it will enhance the safety, effectiveness and efficiency of operations whilst not impinging on or disrupting operations in anyway The SudanMAP QM system is aimed at confirming that mine action organisations are applying their accredited management processes and operational procedures in a manner that will result in the safe, effective and efficient clearance of land. Page 9 of 9