GoM - SCREENING AND MANAGEMENT OF
IMPROVEMENT ACTIONS
PROCEDURE
DOCUMENT NUMBER QUA-PRC-1026
REVISION C1
REVISION DATE 21-Jan-2016
APPLICABILITY Gulf of Mexico
DOCUMENT OWNER Quality Manager
AUTHOR CHECKED BY APPROVED BY
LATEST REVISION James Nelis Quality Bryan Mack James Nelis
Assurance Manager GoM Compliance Manager GoM Quality Assurance Manager
RECORD
GoM
JN 30-Sep-2015 BM 30-Sep-2015 JN 30-Sep-2015
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Wood Group PSN Document No.: QUA-PRC-1026
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1.0 Revision History
Revision Date Details of Changes
A1 30-Sep-2015 Issued for Review
C1 21-Jan-2016 Issued for Use
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Revision History........................................................................................................2
1.0 Purpose........................................................................................................... 4
2.0 Scope...............................................................................................................4
3.0 Glossary of Terms..........................................................................................4
3.1 References...................................................................................................................................... 4
3.2 Abbreviations................................................................................................................................... 4
3.3 Terminology..................................................................................................................................... 5
4.0 Roles & Responsibilities................................................................................5
4.1 Quality Manager.............................................................................................................................. 5
4.2 Compliance Manager......................................................................................................................5
4.3 Project Managers............................................................................................................................ 6
4.4 Auditors........................................................................................................................................... 6
4.5 Investigation Team.......................................................................................................................... 6
5.0 How this procedure works.............................................................................6
5.1 Receipt and Management of Compliance Audit Actions.................................................................6
5.2 Receipt and Management of Internal Actions..................................................................................8
5.3 Internal Actions................................................................................................................................ 9
5.4 Audit / Inspection Actions..............................................................................................................10
6.0 Action Reporting.......................................................................................... 10
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2.0 Purpose
The purpose of this procedure is to define and establish a consistent approach to the screening and
categorisation of improvement actions identified internally or externally in the day to day works undertaken by
WGPSN in our Gulf of Mexico Operations.
For the purpose of this procedure, improvement actions include;
Internal & externally originating non conformities (including regulatory incidents of non- conformance)
Internal & externally originating preventive actions (including regulatory potential incidents of non-
conformance)
Customer feedback (both positive and negative)
This procedure shall be implemented prior to the use of WGPSN’s global improvement processes and the
capture of any actions within the IMPact system.
3.0 Scope
This document applies to all WGPSN GoM operations including actions raised from internal system / process
audits, vendor / supplier / subcontractor audits, technical audit and legal compliance audits.
The document also applies to the management of Bureau of Safety and Environmental Enforcement actions.
4.0 Glossary of Terms
4.1 References
MNT-PRC-1017 GoM - Audit Procedure
MNT-FRM-1038 GoM - Audit Report Template
QUA-PCM-1002 Control of Non Conformance Process Map
MNT-PCM-1015 GoM - Facility Audit Process Map
Note: These references are subject to change. Utilise the iMAP search engine for the latest applicable
references.
4.2 Abbreviations
GoM Gulf of Mexico
NCR Non Conformance Report
PAC Preventive Action
INC Incident of Non-Compliance
PINC Potential Incident of Non-Compliance
BSEE Bureau of Safety and Environmental Enforcement
SEMS Safety Environmental Management System
CFB Customer Feedback
PM Project Manager
HSE Health Safety & Environment
WGPSN Wood Group PSN
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4.3 Terminology
A non-compliance is the failure to adhere to an Act or its Regulations
A non-conformance is the failure to comply with a requirement, standard, or procedure.
Non-conformance: Non-fulfilment of requirements to any given regulation, procedure, process, standard, code
or specification that WGPSN have had the responsibility to manage/deploy.
Incident of Non Compliance: Developed from BSEE is also a non-fulfilment of requirements however it is not
always the responsibility or under the control of WGPSN to manage. Incident of Non Compliance INC’s are
identified by the Potential Incident of Non-Compliance list which BSEE inspectors are trained in identifying issues
that are non-compliant with the regulations.
The classification / definitions are as below.
W=Warning
C=Component Shut in (i.e. 1 component is a Separator, well head, etc.)
S=Structure Shut in
Preventive Action PAC/ Potential Incident of Non – Compliance PINC.
Preventive action that are raised before a failure occurs are raised to prevent a non-conformance/non-
compliance occurring. PAC’s are raised prior to a failure or other undesirable situation occurring (e.g. this may
be a PAC to improve a process to introduce a more efficient / effective way of working, or an improvement to a
policy to ensure it complies with new legislation before it comes into effect)
Customer Feedback CFB: CFB’s are raised as a direct result of communication by the customer to WGPSN,
and can be raised to capture negative and positive feedback.
Correction Action: Correction is the action taken to eliminate the non-conformity/non- compliance, usually this
is the short term action.
Corrective Action: The action to eliminate the cause of the detected non-conformance/non-compliance or
undesirable situation, usually long term and an action that addresses the root cause.
IMPact: WGPSN Preventive Corrective action database
Action: Refers to INC, NCR, PAC, CFB.
5.0 Roles & Responsibilities
5.1 Quality Manager
The Quality Manager is responsible for ensuring that arrangements are established and implemented to meet the
minimum performance expectations as outlined in the key elements of this document. They shall work closely
with operations and functions to facilitate the regular review of performance against the expectations as part of
the assurance framework and feed the results back to the Global Quality function as required.
5.2 Compliance Manager
Compliance Manager is responsible for establishing the audit type (baseline/technical compliance) and
coordinating the auditors to prepare and execute the audits. Reviewing and coordinating the approval of the
applicable Safety & Environmental Management System (SEMS). Working closely with the Quality Manager &
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Project Managers to ensure the arrangements are established and implemented to meet the performance
expectations outlined in the GoM audit process MNT-PRC-1015.
5.3 Project Managers
The Project Manager for the purpose of this document are responsible for ensuring that actions they are
accountable for are formally agreed on discrepancy and communicated to clients. Responsible for the
management of action closures within the agreed period. Providing document evidence of action closure and if
required documented evidence for closure extension dates.
The WGPSN PM shall ensure that the improvement risk matrix captures the action colour coding when
developing the action improvement plan.
The WGPSN PM shall be responsible for interfacing with the client/operator on the classification of the actions
ensuring accountability of the action by the client/operator is verified.
5.4 Auditors
The auditor shall be a competent qualified person responsible for executing the audit as per the audit plan in
compliance with GoM Audit Procedure MNT-PRC-1017 and in the case of loop audits in compliance with the loop
audit process map.
5.5 Investigation Team
The deployment of an investigation team will be dictated by the business risk/exposure that the relevant failure
presents. Investigations shall be undertaken by a single individual or a team of individuals who have sufficient
knowledge and experience where the non – conformance or incident of non-compliance lies. Where possible the
lead in the investigation will have taken training in root cause analysis techniques or be proficient in the
deployment of root cause analysis techniques.
6.0 How this procedure works
The steps and detail outlined in this procedure are designed to assist individuals to validate the correct course of
action to be taken when we receive notification of an improvement action, or identify a potential improvement
action ourselves.
Not all actions are dealt with in the same way and are dependent on a number of factors such as where the
notification of action was received from, what has been requested and who is accountable for doing something
about it.
By applying the simple approach described below we can ensure that all actions received or identified are
screened and managed; and where we have responsibility for completing them, are done so in timely and
professional manner.
6.1 Receipt and Management of Compliance Audit Actions
Before we formally accept and commit to taking on an action from a compliance audit we must review the
circumstances of the proposed action and understand our responsibilities.
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The diagram below provides a simple reference point for anyone receiving notification of an action to explain
what we need to do;
Ste Description Who
p
1 Receive notification of a potential action Employee
2 Review the action to understand the background Quality Mgr., Project Mgr., Compliance Mgr.
3 Confirm if WGPSN are responsible for the action Quality Mgr., Project Mgr., Compliance Mgr.
4 Notify the person issuing the action that’s it’s not WGPSN Employee
action
5 Agree what the action(s) are, who will do it, and by when Quality Mgr., Project Mgr., Compliance Mgr.
6 Confirm if action it goes into IMPact Quality Mgr.,
7 Raise it in IMPact or local tracker WGPSN Employee
6.1.1 Action Review and Classification
It is important that WGPSN firstly understand where accountability for resolving an action lies and whether that
action has been defined as non-confirming (including “incidents of non-compliance” as identified by BSEE) or
‘potentially non-conforming’.
All audit findings or other discrepancies raised must be supported by factual evidence referring to the breach in
regulation, code, standard, specification, procedure or process number, title and clause on the finding report.
Photographic evidence should also be produced as applicable.
Only once WGPSN have reviewed this and identified that we have responsibility for taking action, shall be
assigned to a WGPSN employee to complete and report progress against it.
The audit report shall be reviewed by the compliance manager, quality manager and project manager to enable
accountability and classification be established for actions. The colour coding below provides reference to the
code and action required.
R
Red coded discrepancy is a safety critical action for WGPSN and/or Client action, treated as priority one with
maximum 14 day agreement on correction. If the action is for WGPSN then the action shall be raised in IMPACT.
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If the action is on the client then the client shall be notified by the WGPSN PM and the action recorded on the
internal register, controlled by the WGPSN compliance manager.
Y
Yellow coded discrepancy is not under the control of WGPSN for action and requires client participation, this
action shall not be raised in IMPact, however this action shall be reported to the client by the WGPSN PM and
recorded on an internal register, controlled by the WGPSN compliance manager.
B
Blue coded discrepancy is an action under the control of WGPSN for action and can be entered into IMPACT and
managed under the IMPact preventive and corrective action processes.
Note: If an INC issued by BSEE is at risk of proceeding into the civil penalty status, i.e. a P-103 is having a safety
device by-passed and the device is not being monitored; this shall warrant an investigation that is made up of the
PM, Compliance Manager, Quality Manager, and if required the HSE manager. As per the requirements of the
non -conformance investigation procedure.
INC / PINC/ Green Sheets records once received are stored electronically on the local system and logged for
traceability by the compliance manager or compliance administration support.
If the INC is an issue that our operators could/can fix/repair, then it is up to the operators to do so, i.e. resetting a
PSHL, PSV, or ordering new eye wash bottles and installing once they arrive. If the issue has to deal with
corrosion or specific paperwork that is not filled out on a routine basis, i.e. drawings, permits, those should be
corrected by the client.
If the review process determines the action accountability is with WGPSN then the action shall be managed
using the IMPact system.
6.2 Receipt and Management of Internal Actions
All WGPSN accountable actions shall be recorded in IMPact as per WGPSN Non-Conformance & Preventive
Action process.
Actions referenced as per section 5.1.1 of this document once classified as WGPSN actions shall also be
recorded in IMPact using the diagram below for reference.
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Step Phase Description Who
1 Identify Identify new action Originator
2 Agree Agree action with Actionee Originator
3 Produce Login & create IMPact Originator
4 Review Review action and approve or reject IMPact Focal Point
5 Notify Email notification to originator & actionee IMPact
6 Implement Implement agreed actions in agreed Actionee
timescales
7 Propose Closeout Enter proposed closeout along with supporting Actionee
evidence into IMPact for Focal Point
verification
8 Notify Email notification to IMPact Focal Point of IMPact
pending closeout
9 Verify Verify evidence that action is complete and IMPact Focal Point
approve or reject accordingly
10 Notify Email notification to originator & actionee of IMPact
closure
6.3 Internal Actions
Actions originated and controlled by WGPSN during internal process audits, contractor/supplier/sub - contractor
audits or inspections shall be addressed as below:
The originator shall discuss the findings with the actionee ensuring agreement on:
The review of circumstances of potential action and confirm the action is valid.
The factual evidence presented.
The Correction & Corrective or Preventive Action as applicable.
Closure dates.
It is imperative that the action description, action party and target action dates are agreed prior to input into
IMPact. Failure to do so may result in the action being rejected due to lack of factual information.
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In exceptional circumstance the originator will be required to provide detailed information explaining why the
correction lacks information to achieve action closure as per the agreed closure date. After review of information
the focal point can agree to the closure date being extended.
Formal notification shall be issued electronically to the actionee once the finding is uploaded into IMPact.
6.3.1 Tracking and Closure of Internal actions.
On agreement and upload of the action into IMPact the action shall be tracked by the originator and monitored by
the IMPACT focal point to ensure dates are reached.
If there is a risk the date of closure shall be exceeded the actionee shall be required to produce documented
evidence to the originator for approval of agreed extension to closure dates. This will formally be tracked in the
IMPact system for verification of extension.
6.4 Audit / Inspection Actions
Actions raised by WGPSN that cannot be controlled to a closure by WGPSN (client – operator controlled
actions), however still cause possible risk to WGPSN operations and resources shall be recorded and reported to
the applicable client / operator.
However this type of action cannot be reported as an overdue action on WGPSN, failure to close the action by a
client or operator after the agreed period shall result in the action being raised to WGPSN senior management
and possible regulatory body.
Although closure of the action maybe out with WGPSN controls, the action will still require to be tracked by
WGPSN compliance manager on the internal register, (this would not be captured in IMPact).
7.0 Action Reporting
IMPact reports are provided to the WGPSN Leadership team each month as part of the Quality Report by the
Quality function.
The purpose of these reports is to regularly highlight trends and issues relating to the data held within IMPact.
These shall typically include, but are not limited to:
Open v Overdue Actions.
Actions reaching overdue status.
Trend Analysis – origins of repeat issues.
IMPact induction completed.
Audit Compliance actions shall require critical attention for closure, overdue actions are required to be addressed
at a formal meeting by the operations manager, project manager, and compliance manager at the 30 and 60 day
overdue status.
Actions 90 days or more overdue shall be elevated to the VP and executive VP of operations for review.
All GoM IMPact actions are recorded on the global quality report and subject to review by EXCOM.
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