NON-CONFORMANCE AND

PREVENTIVE AND CORRECTIVE

ACTION Office of Occupational Health and Safety
Issue Date: October 22, 2007 Doc. No: OHS-5.3.1
Review Date: Approved By: V.P. Admin & Finance
Revision Date: New Page: 1 of 4

1.0 PURPOSE
The purpose of this procedure is to define a method for addressing non-conformances, determining the root
cause, and implementing corrective and preventative action.

2.0 SCOPE
This procedure addresses corrective and preventive actions identified in occupational health and safety (OHS)
system audits and during the ongoing company OHS activities.

3.0 DEFINITIONS
OHS: Occupational health and safety
PCA: Preventive/corrective action
Non-conformance: any deviation from work standards, practices, procedures, regulations, management system
performance etc. that could either directly or indirectly lead to injury or illness, property damage, damage to the
workplace environment, or a combination of these.
Corrective action: action to eliminate the cause of a detected non-conformity with the OHS system.
Preventive action: action to eliminate the cause of a potential non-conformity with the OHS system.
Major / Critical hazards or accidents: those that have the potential for or actually cause loss of life, body part,
and or extensive loss of structure, equipment or material. PCA must be implemented immediately or within 24
hours.
Moderate / Serious hazards or accidents: those that have the potential for or actually cause serious injury,
illness or property damage. PCA must be implemented within 7 days.
Minor hazards or accidents: those that have the potential for or actually cause non-disabling injury or non-
disruptive property damage. PCA must be implemented within 30 days.
Minor non-conformity: an isolated incident or partial breakdown of a process within OHS system not causing
critical injury.
Moderate non-conformity: multiple or recurring "minor" incidents,
Major non-conformity: a total breakdown of a process within OHS system, or a partial breakdown of the system
resulting in a critical injury.
Opportunity for improvement: suggestions for improving the OHS system.

4.0 RESPONSIBILITIES
Office of OHS: is responsible for ensuring corrective action is taken when actual deficiencies are identified.

5.0 REFERENCE DOCUMENTS

OHS-4.5.2 Right to Refuse Unsafe Work
OHS-5.1.1 Workplace Inspections
OHS-5.2.1 Hazard Identification and Correction
OHS-5.2.2 Accident/Incident Reporting

Printed versions of this document are considered uncontrolled. A controlled copy of this document is located on the
University of Windsor Occupational Health & Safety website, www.uwindsor.ca/safety.
 NON-CONFORMANCE AND
PREVENTIVE AND CORRECTIVE
ACTION Office of Occupational Health and Safety
Issue Date: October 22, 2007 Doc. No: OHS-5.3.1
Review Date: Approved By: V.P. Admin & Finance
Revision Date: New Page: 2 of 4

OHS-5.3.1a Preventive and Corrective Action Form

OHS-5.3.1b Preventive and Corrective Action Report Log
OHS-6.1 Management Review

6.0 PROCEDURE
Preventive actions
Preventive actions are typically generated when a non-conformance has not occurred, though data, trends,
incidents/near misses, or observations suggest that a non-conformance could potentially occur. The University
of Windsor will use the following activities to identify the need for preventive action.
• Central Safety Committee (CSC) meetings: this meeting ensures consultation on problems and solutions.
Each quarter, all actions are followed up for status. This meeting ensures statistical analysis of accident
data is reviewed to prevent future incidents.
• Audit reports: annual OHS audits will be carried out. An action plan on corrective solutions can include
accident prevention procedures.
• Safety inspections: regular safety inspections implement action plans that aim at accident prevention.
These are described in Workplace Inspections (OHS-5.1.1).
• Management review: Management will conduct an annual review of the OHS program. These top
management meetings discuss and implement accident prevention policies and procedures. Any
outstanding actions are reported to top management at the earliest opportunity in any of the described
meetings.
Corrective actions
Corrective actions are typically generated as a result of repetitive errors, employee suggestions, complaints,
process non-conformances, internal audits and identification of other OHS hazards or system deficiencies.
Use of the Preventive and Corrective Action Form
Any employee is entitled to request corrective action on any non-conformity related to OHS issues by completing
section A of the Preventive and Corrective Action Form in conjunction with the manager/supervisor or equivalent
to describe the hazard. The manager/supervisor or equivalent is responsible for completing Section B to identify
the root cause and PCA. The process for reporting hazards is described in Hazard Identification and Correction
(OHS-5.2.1).
Section A
Any individual who initiates the PCA process is referred to as the “initiator” and is required to complete Section A
of the PCA Form. In this section, the initiator describes the problem and identifies the reason which prompted
him/her to complete the form (e.g. hazardous condition observed, audit, workplace inspection, work refusal,
accident/incident, or non-conformance with OHS system). Non-conformances, hazards and accidents/injuries will
be rated as Major, Moderate, Minor or Opportunity for Improvement as described in the Definitions in this
procedure. In some cases, such as an accident where medical aid is sought, information such as witness
statements and photographs may be required. The form prompts the initiator to consider the need for this
information prior to identifying PCA.
Section B
If someone other than the initiator is responsible for completing the form and ensuring PCA is implemented (e.g.
in the case of a worker reporting a hazard, or an inspector observing an issue), another individual called the

Printed versions of this document are considered uncontrolled. A controlled copy of this document is located on the
University of Windsor Occupational Health & Safety website, www.uwindsor.ca/safety.
 NON-CONFORMANCE AND
PREVENTIVE AND CORRECTIVE
ACTION Office of Occupational Health and Safety
Issue Date: October 22, 2007 Doc. No: OHS-5.3.1
Review Date: Approved By: V.P. Admin & Finance
Revision Date: New Page: 3 of 4

“implementer” is responsible for the PCA. This will typically be a manager/supervisor or equivalent. If the
Initiator of the PCA process will also be implementing PCA (e.g. when the initiator is a manager/supervisor or
equivalent, CSC member, or senior management), the initiator may complete Section B as the implementer.
The implementer will identify any immediate actions that were or will be taken at location to prevent the
issue/event from causing injury to others (e.g. isolate hazard, remove hazard, lock out, post signage, and/or
restrict access). The implementer will determine the root cause(s) of the issue/event, the proposed action(s)
and a target completion date(s) in Section B. In this section the implementer is also required to identify whether
or not new risks will be created as a result of the proposed PCA. If there is a risk, the PCA should not be taken
and the OHS Manager should be contacted for guidance. For each proposed PCA, the implementer will identify a
responsible party (which may be himself/herself or others), the departments affected by the PCA, and due date.
In cases where the PCA will not be implemented for an extended period (greater than one month), an interim
PCA must be implemented. Examples of corrective actions include but are not limited to:
• Instruction of persons involved;
• Reassignment of persons;
• Improved PPE;
• Correction of congested area/storage;
• Installation of guard or safety device;
• Inform all department supervision; and
• Discipline of person(s) involved.
Preventive actions should also be identified and implemented when a corrective action is implemented in order
to prevent reoccurrence of the issue in similar areas throughout the University.
The implementer will return a copy of the Preventive and Corrective Action Form with Section B completed and
their signatures in Section D to the Office of OHS. The Office of OHS will record the PCA in the Preventive and
Corrective Action Report Log. The Office of OHS will follow up with the implementer to determine when the PCA
is completed and document its completion on the PCA form.
Section C
The implementer will contact the Office of OHS to confirm completion of the PCA. The implementer will discuss
the action taken and the outcome with the initiator, if different than the implementer. Where PCA are not taken
in a reasonable time frame, these will be forwarded to the Co-chairs of the CSC for follow up.
The initiator, a CSC member or the OHS manager will review the action taken to verify that it was effective. The
Office of OHS will review the Preventive and Corrective Action Forms and Report Log at least monthly to ensure
that all PCA have been addressed or are on schedule.
Communication of PCA
The Office of OHS will provide management with a current copy of the log for their annual management review
meeting. Management will review the log and discuss open preventive/corrective action projects. Discussion
may include:
• The nature of the preventive/corrective action (what is it?)
• The action plan (what are we going to do to resolve it?)
• The current status of the action plan (what has been done?)
• A summary of any problems affecting the completion date.

Printed versions of this document are considered uncontrolled. A controlled copy of this document is located on the
University of Windsor Occupational Health & Safety website, www.uwindsor.ca/safety.
 NON-CONFORMANCE AND
PREVENTIVE AND CORRECTIVE
ACTION Office of Occupational Health and Safety
Issue Date: October 22, 2007 Doc. No: OHS-5.3.1
Review Date: Approved By: V.P. Admin & Finance
Revision Date: New Page: 4 of 4

The Office of OHS will also provide the CSC with a current copy of the log prior to their quarterly meetings for
review.

7.0 REVISION HISTORY

Date Revision
(yyyy/mm/dd)

Printed versions of this document are considered uncontrolled. A controlled copy of this document is located on the
University of Windsor Occupational Health & Safety website, www.uwindsor.ca/safety.