3221-C2-V5+V6-CAR Corrective Action [PDF]

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NOTE Please complete the Action Plan of (all) CAR(s), save it (them) to the same file name *.doc and send the file to [email protected] and [email protected] within 5 calendar days starting from the date of closing meeting.



Corrective Action Request CAR 1 of 5 Major Organization: Site(s) audited:



Auditor(s): Standard(s): Organization Representative: Area / Department / Process: Document Ref.: Issue/Rev. Status:



Minor



PT Satkomindo Mediyasa Jl. RS Fatmawati No. 1 RT 002/008 Date(s) of audit(s): Cilandak Barat-Jakarta Selatan 12430, Indonesia Dwi Wahyu Wijayatmoko, Achmad Arief Nugroho ISO 9001:2015 and OHSAS 18001:2007 Mr.Dede Suryadi



24-25 January 2018



MR Prosedur Pengendalian Dokumen, Doc.No.CORP/SOP/2016, Edition:.2.0, dated: 02/01/18



Standard Ref.:



ISO 9001:2015 Clause: 7.5.1



CAR Close out date:



Details of Non-Conformity: The documented information procedure has been established as seen on Prosedure Pengendalian Dokumen, Doc.No.CORP/SOP/2016, however the documented information does not include : - Documented information required by ISO 9001:2015. - Documented information determined by the organization as being necessary for the effectiveness of the quality management system where the extent of documented information for a quality management system can differ from one organization to another due to: - Size of organization and its type of activities, processes, products and services; - The complexity of processes and their interactions; - The competence of persons. Organization Representative:



Mr.Dede Suryadi



Auditor:



Dwi Wahyu Wijayatmoko



Cause Analysis and Corrective Action taken to prevent recurrence: Cause Analysis: There is not all the documented information have been compiled and registered by organisation



Corrective Action: The organisation shall registered and compiled completed documented information affected to organisation activity as required by ISO9001 : 2015



Organization Representative:



Date:



29.01.2018



Dede.S.



Acceptance of Corrective Action / Comments (use additional sheets if necessary): Documented information determined by the organization as being necessary for the effectiveness of the quality management system where the extent of documented information for a quality management system will be issued as required. Effectively soon as confirmed by organization and disseminated to all organization. Job / Cert. n°: Document:



ID/JKT 3221 3221-C2-V5+V6-CAR



Visit Type: Surveillance+Upgrade Visit n°: Issue n°: 5 Page n°:



05+06 1 of 7



NOTE Please complete the Action Plan of (all) CAR(s), save it (them) to the same file name *.doc and send the file to [email protected] and [email protected] within 5 calendar days starting from the date of closing meeting.



Auditor:



Date: Response required (in months)



Major



Define Corrective Action must be addressed within time frame stated. Verification of action will occur at next visit. Additional follow up may be required as indicated.



Minor



Close Out



Define



Close Out



Corrective Action Request CAR 2 of 5 Major Organization:



Minor



PT Satkomindo Mediyasa Jl. RS Fatmawati No. 1 RT 002/008 Date(s) of audit(s): Cilandak Barat-Jakarta Selatan 12430, Indonesia Dwi Wahyu Wijayatmoko, Achmad Arief Nugroho ISO 9001:2015 and OHSAS 18001:2007 Mr.Dede Suryadi



Site(s) audited:



Auditor(s): Standard(s): Organization Representative: Area / Department / Process: Document Ref.:



24-25 January 2018



MR



Issue/Rev. Status:



QOHS Manual (Doc.No.CORP/SOP/2018) Edition:.2.0, dated: 02/01/18



Standard Ref.: CAR Close out date:



ISO 9001:2015 Clause: 8.5.6 Next visit



Details of Non-Conformity: There are some changing of the organization such as: office building and organization structure where since effective by 27/12/17 the operational office has been moved to new location, however inadequate evidence that management of change has been provided and reviewed to ensure continuing conformity with requirements where documented information describing the results of the review of changes, The person(s) authorizing the change, and any necessary actions arising from the review should be retained. Organization Representative:



Mr.Dede Suryadi



Auditor:



Dwi Wahyu Wijayatmoko



Cause Analysis and Corrective Action taken to prevent recurrence: Cause Analysis: Find that the organisation not ensure have procedure or rule how to maintain if there are changing authority or task or moving place.



Corrective Action: The organisation should established a documented procedure to cope if there are activity in the organisation which need to change personnel or activity or location. the documented information should issued immediately.



Organization Job / Cert. n°: Document:



Dede S. ID/JKT 3221 3221-C2-V5+V6-CAR



Date:



29.01.2018 Visit Type: Surveillance+Upgrade Visit n°: Issue n°: 5 Page n°:



05+06 2 of 7



NOTE Please complete the Action Plan of (all) CAR(s), save it (them) to the same file name *.doc and send the file to [email protected] and [email protected] within 5 calendar days starting from the date of closing meeting.



Representative: Acceptance of Corrective Action / Comments (use additional sheets if necessary): Some changing of the organization such as: office building and organization structure where since effective by 27/12/17 the operational office has been moved to new location, and evidence that management of change has been provided and reviewed to ensure continuing conformity with requirements with documented information describing the results of the review of changes.



Auditor:



Dede S



Date:



29.01.2018



Response required (in months)



Major



Corrective Action must be addressed within time frame stated. Verification of action will occur at next visit. Additional follow up may be required as indicated.



Define



Minor



Close Out



Define



Close Out



Corrective Action Request CAR 3 of 5 Major Organization: Site(s) audited:



Auditor(s): Standard(s): Organization Representative: Area / Department / Process: Document Ref.: Issue/Rev. Status:



Minor



PT Satkomindo Mediyasa Jl. RS Fatmawati No. 1 RT 002/008 Date(s) of audit(s): Cilandak Barat-Jakarta Selatan 12430, Indonesia Dwi Wahyu Wijayatmoko, Achmad Arief Nugroho ISO 9001:2015 and OHSAS 18001:2007 Mr.Dede Suryadi



24-25 January 2018



P2K3 Doc. CORP/SOP/2018,



Standard Ref.:



Date 02/01/2018



CAR Close out date:



OHSAS 18001:2007 Clause : 4.3.2 & 4.5.2 Next visit



Details of Non-Conformity: 1. The identifying and reviewing applicable legal requirements is not effectively maintained to ensure that its always updated and evaluated properly, as bellows : 1. Some applicable legal requirements are not yet identified and evaluated, for instances : Health regulation - UU no.36/2009 re’ Kesehatan - PMK no 70/2016 re’ Standard dan persyaratan kesehatan lingkungan replace Kemenkes N0.1405/2002 - PMK no.32/2017 re’ Standard baku mutu kesehatan lingkungan dan persyaratan kesehatan air untuk keperluan higine sanitasi Fire protection system - Permen PU.no26/2008 re’ system proteksi kebakaran pada gedung dan lingkungan - Pergub DKI no.143/2016 Re’ manajemen Keselamatan kebakaran gedung New regulation - Permenaker No.03/1999 amanded to Permenaker 32/2015 re’ Syarat2 K3 lift - Permenaker 02/1989 amanded toPermenaker 31/2015 re’ pengawasan instalasi penyalur petir - Permanaker 04/1985 amanded to Permanaker no.38/2016re’ K3 pesawat tenaga dan Job / Cert. n°: Document:



ID/JKT 3221 3221-C2-V5+V6-CAR



Visit Type: Surveillance+Upgrade Visit n°: Issue n°: 5 Page n°:



05+06 3 of 7



NOTE Please complete the Action Plan of (all) CAR(s), save it (them) to the same file name *.doc and send the file to [email protected] and [email protected] within 5 calendar days starting from the date of closing meeting.



-



produksi. Permanaker no.09/2016 re’ K3 dalam pekerjaan pada ketinggian.



2. Insufficient evidence that lighting arrester permit available for new building (BRI NetcomFatmawati) as required by Permanaker no.31/2015.



Organization Representative:



Mr.Dede Suryadi



Auditor:



AAN



Cause Analysis and Corrective Action taken to prevent recurrence: Cause Analysis: The organisation not ensure have maintained and fulfil K3 Regulation and requirements as stated. Also there is not evidence that regulation and requirements already comply.



Corrective Action: All the regulation and requirements that affected and link to organisation activity will be documented and evaluated regularly as intended period. Also the organisation should fulfilled regarding regulation needs due to provided by building management such as: Lift, Thunder arrester, Moving equipment and etc.



Organization Representative:



Dede S.



Date:



29.01.2018



Acceptance of Corrective Action / Comments (use additional sheets if necessary): The organisation issued a list of regulation and requirements and evaluated effectivity periodically.



Auditor:



Date: Response required (in months)



Major



Define Corrective Action must be addressed within time frame stated. Verification of action will occur at next visit. Additional follow up may be required as indicated.



Minor



Close Out



Define



Close Out



Corrective Action Request CAR 4 of 5 Major Organization: Site(s) audited:



Auditor(s): Standard(s): Organization Representative: Area / Department / Process: Document Ref.: Job / Cert. n°: Document:



Minor



PT Satkomindo Mediyasa Jl. RS Fatmawati No. 1 RT 002/008 Date(s) of audit(s): Cilandak Barat-Jakarta Selatan 12430, Indonesia Dwi Wahyu Wijayatmoko, Achmad Arief Nugroho ISO 9001:2015 and OHSAS 18001:2007 Mr.Dede Suryadi



24-25 January 2018



P2K3 & Human capital (SDM) SHEP Manual



ID/JKT 3221 3221-C2-V5+V6-CAR



Standard Ref.:



OHSAS 18001:2007



Visit Type: Surveillance+Upgrade Visit n°: Issue n°: 5 Page n°:



05+06 4 of 7



NOTE Please complete the Action Plan of (all) CAR(s), save it (them) to the same file name *.doc and send the file to [email protected] and [email protected] within 5 calendar days starting from the date of closing meeting.



SK.No.068-DIR/GA/XI/2017 SK.no.010-DIR/UMM/SDM/II/2012



Clause 4.4.2



Issue/Rev. Status:



CAR Close out date:



Next visit



Details of Non-Conformity: 1. See in doc. Job description for GA staff whose appointed as electrical technician that roles, responsible and competencies related to electrical not yet define. Furthermore, training needs associated with its OHS risk to fullfill compliance are not clearly determine in matrix competencies, e.g: LOTO, Electrical competencies or electrical certificate. 2. Seen in doc. Susunan ERT team as SK.No.068-DIR/GA/XI/2017 – covering : ketua, wakil, secretary, tim tanggap darurat (captain floor 1-4), tim tanggap darurat, kebakaran dan bencana alam, tim tanggap darurat kecelakaan & P3K . However, standard competencies for those position not yet determine as functional structural.



Organization Representative:



Mr.Dede Suryadi



Auditor:



AAN



Cause Analysis and Corrective Action taken to prevent recurrence: Cause Analysis: Find that Job description for GA staff whose appointed as electrical technician that roles, responsible and competencies related to electrical not yet define.



Corrective Action: The organization established documented procedure that stated about job competencies, roles, responsible that affected with daily activity and evaluated regularly.



Organization Representative:



Date:



Acceptance of Corrective Action / Comments (use additional sheets if necessary): Documented procedure stated about job descrition, job competencies, roles, responsibility of organisation activity established at functional structural and evaluated periodically.



Auditor:



Date: Response required (in months)



Major



Define Corrective Action must be addressed within time frame stated. Verification of action will occur at next visit. Additional follow up may be required as indicated.



Close Out



Minor Define



Close Out



Corrective Action Request CAR 5 of 5 Major



Job / Cert. n°: Document:



ID/JKT 3221 3221-C2-V5+V6-CAR



Minor



Visit Type: Surveillance+Upgrade Visit n°: Issue n°: 5 Page n°:



05+06 5 of 7



NOTE Please complete the Action Plan of (all) CAR(s), save it (them) to the same file name *.doc and send the file to [email protected] and [email protected] within 5 calendar days starting from the date of closing meeting.



Organization:



PT Satkomindo Mediyasa Jl. RS Fatmawati No. 1 RT 002/008 Date(s) of audit(s): Cilandak Barat-Jakarta Selatan 12430, Indonesia Dwi Wahyu Wijayatmoko, Achmad Arief Nugroho ISO 9001:2015 and OHSAS 18001:2007 Mr.Dede Suryadi



Site(s) audited:



Auditor(s): Standard(s): Organization Representative: Area / Department / Process: Document Ref.:



24-25 January 2018



MR



Issue/Rev. Status:



CORP/SOP/2018



Standard Ref.:



Rev.2.0



CAR Close out date:



ISO 9001:2015 & OHSAS 18001:2007 Clause 9.2.1 (9K), 4.5.5 (18K) Next visit



Details of Non-Conformity: 1. Internal audit was carried out on 13/10/2017 – 19/10/2017, however insufficient evidence that clause 4.1, 4.2, & 6.1.1 for ISO 9001:2015 and 4.4.6, 4.4.7 and 4.5.1 for OHSAS 18001:2007 has been covered in internal audit. 2. Furthermore, insufficient evidence that causes of analysis not yet defined from the internal audit result as seen in Form (F-K3-019) ketidak sesuaian (internal audit).



Organization Representative:



Mr.Dede Suryadi



Auditor:



Dwi Wahyu Wijayatmoko



Cause Analysis and Corrective Action taken to prevent recurrence: Cause Analysis: The organisation not ensure already audited based on clause requirements as audited based on activity as well. Also not clearly defined that finding result reflected as stated on Non Conformity Report.



Corrective Action: The organisation will be held audit based on clause and activity as required, and stated on documented procedure that include comptele process as on P-D-C-A. The procedure will be evaluated and updated regularly.



Organization Representative:



Dede S.



Date:



29.01.2018



Acceptance of Corrective Action / Comments (use additional sheets if necessary): Organisation established Audit Process Documented Procedure that stated schedule, check sheet, location issued, form and disseminate to designed process, the procedure will be evaluated periodically.



Auditor:



Date: Response required (in months)



Major



Define Corrective Action must be addressed within time frame stated. Verification of action will occur at next visit. Additional follow up may be required as indicated. Job / Cert. n°: Document:



ID/JKT 3221 3221-C2-V5+V6-CAR



Close Out



Minor Define



Close Out



Visit Type: Surveillance+Upgrade Visit n°: Issue n°: 5 Page n°:



05+06 6 of 7



NOTE Please complete the Action Plan of (all) CAR(s), save it (them) to the same file name *.doc and send the file to [email protected] and [email protected] within 5 calendar days starting from the date of closing meeting.



Job / Cert. n°: Document:



ID/JKT 3221 3221-C2-V5+V6-CAR



Visit Type: Surveillance+Upgrade Visit n°: Issue n°: 5 Page n°:



05+06 7 of 7