2008 Nov Pcoc Qm Template

TRANSPORT CANADA MARINE SAFETY PLEASURE CRAFT OPERATOR COMPETENCY PROGRAM

QUALITY MANAGEMENT SYSTEM FOR ACCREDITATION OF COURSE PROVIDERS PROJECT TRANSITION AND IMPLEMENTATION

PLEASURE CRAFT OPERATOR COMPETENCY PROGRAM QUALITY MANUAL TEMPLATE FOR COURSE PROVIDERS FINAL DRAFT V2.6 Fujitsu Consulting 31 July 2008 Reference: 126123

QUALITY MANUAL

Preface to the Quality Manual Template A Quality Manual is a formal and authorized document that outlines your intention as a Course Provider to operate in an effective and controlled manner. It sets out the quality policies, procedures and practices which comprise your quality management system (QMS). This Quality Manual template is intended to serve as a tool for the production of individual Course Provider Quality Manuals as required and recognized by the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements. This Quality Manual template is designed with a series of instructions and/or guidance provided at the start of each section in grey-shaded boxes. The template is also designed for you to delete, at some point, the instructions and guidance thus giving you a final Quality Manual for your organization. It is suggested that you thoroughly review the provided instructions and guidance and do not delete them until you have a near-final Quality Manual document. The Quality Manual template has also been designed for you to personalize the document (text outside the shaded boxes) to your organization. Therefore, any text that is italicized is only an example or suggested text for the respective section and you are encouraged to review and amend this text to suit your particular organization and requirements. The final version of your text should be changed from italics to normal font. Additionally, you will see suggested wording options, in some sections, that are provided within the less than and greater than symbols for example < Business Owner or senior management>. You can simply delete the < > symbols and the words that do not apply and, again, change the font from italics to normal. In the case where none of the provided words/options apply, simply delete the symbols and italicized text and insert your own text in normal font. One additional tool that can help in your preparation for accreditation and for assessing accreditation readiness is the QMS Self-Assessment Checklist that is found at Appendix B to this Quality Manual. Appendix A Glossary defines selected terminology, and defines the meaning of abbreviations and acronyms used throughout this document.

Dos and Donts to Facilitate Preparation of Your Quality Manual 1. Do thoroughly familiarize yourself with this document. 2. Do review your organizations operations to ensure that requirements in the Quality

Manual are consistent with your operation and are being performed. Identify any gaps and differences in your operations, including existing applicable documentation, such as policies, procedures, and protocols (e.g. Test Protocol) and ensure you have transitioned to the latest Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements.

3. Do update your Quality Manual cover page and header(s) and footer(s). 4. Do delete and remove all explanatory information (all text in the grey-shaded

explanation boxes) from your Quality Manual. 5. Do delete the Forward page. 6. Do delete the example Quality Policy Statement and replace it with your Quality

Policy.

QUALITY MANUAL Issue Date dd-mmm-yyyy

QUALITY MANAGEMENT SYSTEM Document No xx Revision 0

Quality Manual Revision 0 Date Issued: 31 July 2008

7. Do amend the list of QMS documentation and documentation mediums, as applicable.

8. Do reference your applicable Provincial/Territorial Freedom of Information and Protection of Privacy Act and Personal Information Protection and Electronic Documents Act, as appropriate. Do add and/or delete references in Appendix E References, as applicable.

9. Do delete the example Organizational Chart and replace it with your Organizational Chart.

10. Do adjust roles, responsibilities, and authorities, where appropriate, for your organization.

11. Do identify the advertised official language(s) in which you offer your Course Provider services.

12. Do adjust the list of Client and Transport Canada communications channels and arrangements, where appropriate, for your organization.

13. Do adjust the list of Client satisfaction methods, as applicable. 14. Do add and define any terminology, abbreviations and acronyms specific to your

organization and used in your Quality Manual in Appendix A Glossary. 15. Do document the name(s) and title(s) and obtain approvals of duly authorized

Business Owner, Designed Senior Manager and/or senior management responsible for the quality of the delivery of your client services.

16. Do take the opportunity to utilize the QMS Self-Assessment Checklist, found at Appendix B to this manual, to prepare your organization for and to maintain accreditation;

17. Do Not use the example Quality Policy Statement verbatim. Use the example as a guide for your organizations Quality Policy.

18. Do Not include proprietary information or highly sensitive material in your Quality Manual.

19. Do Not assume a complete QMS is compliant with the requirements of ISO 9001:2000 International Standard for Quality Systems.


Responsible Authority The Business Owner or Designated Senior Manager is responsible for this document, including any change, correction or update.

Approved By ................................................................ First name, Last name Title

................................................................ First name, Last name Title



Template Version Version / Revision: 2.6 Date Issued: 31 July 2008


Revision History Amendment No. Date Pages Affected Date Entered Initials

QUALITY MANUAL Page i of i QUALITY MANAGEMENT SYSTEM

Document No xx TABLE OF CONTENTS Revision 0


FORWARD........................................................................................................................1 A QUALITY POLICY STATEMENT...............................................................................2 B POLICIES AND PROCEDURES ...............................................................................4 1. QUALITY MANAGEMENT SYSTEM.........................................................................4

1.1 Documentation Requirements ......................................................................................... 4 1.1.1 Quality Manual............................................................................................................. 5 1.1.2 Control of Documents.................................................................................................. 6 1.1.3 Control of Records....................................................................................................... 8 1.1.4 Record Submissions to Transport Canada ................................................................. 9

2. MANAGEMENT RESPONSIBILITY.........................................................................11 2.1 Management Commitment.............................................................................................. 11 2.2 Roles, Responsibilities and Authorities........................................................................ 12

2.2.1 Business Owner or Designated Senior Manager ...................................................... 13 2.2.2 Quality Coordinator.................................................................................................... 14 2.2.3 All Staff ...................................................................................................................... 15

2.3 Management Review ....................................................................................................... 16 3. DELIVERY OF COURSE PROVIDER SERVICES..................................................19

3.1 Official Language............................................................................................................. 19 3.2 Client Communication .................................................................................................... 19 3.3 Transport Canada Communication................................................................................ 20 3.4 Transport Canada Supplied Materials........................................................................... 20

4. MEASUREMENT, ANALYSIS AND IMPROVEMENT .............................................22 4.1 Client Satisfaction ........................................................................................................... 22 4.2 Transport Canada Accreditation Requirements........................................................... 22 4.3 Client Feedback ............................................................................................................... 23 4.4 Transport Canada Feedback .......................................................................................... 24 4.5 Internal Audit.................................................................................................................... 25 4.6 External Audit .................................................................................................................. 27 4.7 Control of Non-conformances........................................................................................ 29 4.8 Corrective Action............................................................................................................. 29 4.9 Preventive Action ............................................................................................................ 31

C APPENDICES..........................................................................................................33 APPENDIX A GLOSSARY...........................................................................................33

Acronyms and Abbreviations................................................................................................. 33 Terminology ............................................................................................................................. 33

APPENDIX B QMS SELF-ASSESSMENT CHECKLIST .............................................38 APPENDIX C REQUIRED DOCUMENTATION CHECKLIST .....................................46 APPENDIX D REQUIRED RECORDS CHECKLIST ...................................................47 APPENDIX E REFERENCES......................................................................................48

QUALITY MANUAL Page 1 of 48 QUALITY MANAGEMENT SYSTEM

Document No xx QUALITY POLICY Revision 0


FORWARD The Course Provider Quality Manual shall be the main document for your quality management system (QMS). The purpose of the Course Provider Quality Manual is to state your organizations philosophy, policy and procedures towards satisfying all Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements for a QMS, and in doing so, demonstrate your commitment, as Business Owner, Designated Senior Manager and/or senior management, to the management of this program within your organization. Your Quality Manual also describes in the form of policies and individual procedures how the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements for a QMS will be implemented within your organization. Further evidence of your commitment as Business Owner, Designated Senior Manager and/or senior management is demonstrated in a number of ways including: the development, implementation and continual improvement of your quality management system (QMS); ongoing communication of its effectiveness to all your staff, including agents administering tests and agents performing other business functions, both temporary and one-time agents; and, ongoing communications regarding the importance of meeting Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements, meeting client expectations and delivering quality client services. Finally, your Quality Manual is a controlled document and only controlled copies are to be used to implement your QMS.

The purpose of this < Company Name Here> Quality Manual is to state philosophy, policy and procedures towards satisfying all Transport Canada Pleasure Craft Operator Competency Program Accreditation Requirements for a quality management system (QMS) and demonstrates commitment to the management of this program within this organization.

The < Company Name Here> Quality Manual details the policies and individual procedures for the implementation of the Transport Canada Pleasure Craft Operator Competency Program within this organization.

ongoing commitment to these policies and procedures will be demonstrated through:

Development, implementation and continual improvement of the QMS; Ongoing communication of the QMS effectiveness to all staff; Ongoing communications regarding the importance of meeting Transport Canada

Accreditation Requirements, meeting client expectations and delivering quality client services; and

. This < Company Name Here> Quality Manual is a controlled document and controlled copies will be maintained and distributed accordingly.




A QUALITY POLICY STATEMENT Your commitment to the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements is supported by your Quality Policy Statement. As part of your quality management system (QMS) you must issue a Quality Policy Statement approved by the Business Owner or the Designated Senior Manager. This Quality Policy Statement is written so that it is appropriate to the purpose of your organization. It is written in language that is easy to understand and expresses the overall intentions and direction of your organization related to the quality of delivery of your Course Provider client services. It shall include a commitment to: Meet or exceed client satisfaction with your Course Provider services; Continually comply with the Transport Canada Pleasure Craft Operator

Competency Program - Accreditation Requirements; Continually improve the effectiveness of the quality management system (QMS); Communicate the Quality Policy Statement within your organization, including

communication to all agents administering tests and/or all agents performing other business functions, on behalf of your organization, including temporary or one-time agents;

Ensure the Quality Policy Statement is understood within your organization; and Review the Quality Policy Statement for continuing suitability.

The Quality Policy Statement states:

Preface to Quality Policy Statement Example This example Quality Policy Statement is intended to serve as a tool to guide your organization in the development of its Quality Policy. Because a Quality Policy shapes your organizations approach to Course Provider services and quality assurance, the Quality Policy Statement must be approved by your Business Owner or Designated Senior Manager. Your Quality Policy Statement should indicate who will be fulfilling the role of Quality Coordinator in your organization (refer to Section 2.2.2 of this document). In smaller organizations, the Business Owner may choose to take on this role due to insufficient staff or expertise. The Business Owner may also choose to acquire the services of an external Quality consultant, in accordance with the selection guidance provided separately, to provide advice and perform some of all of the roles of the Quality Coordinator. The Quality Policy Statement must reflect your organizations commitment to quality, continuous improvement, and client satisfaction. It must be: Linked to your organizational goals; Be relevant to the needs and expectations of your clients and Transport Canada;

and State your organizations quality objectives.

The < Company Name Here> is committed to providing and delivering high quality Course Provider services to consistently achieve client and Transport Canada satisfaction, and to promote and ensure operator safety and competency in the marine environment.




Our policy will be achieved through:

Exceeding client expectations with our services; Committing to a quality management system (QMS) that satisfies the

requirements as outlined in the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements;

Meeting and exceeding our accreditation commitments; Implementing, following and pursuing a quality management system (QMS) that

fosters a quality culture across the organization and supports continuous improvement;

Working with our clients and Transport Canada to monitor our success and to continuously evolve and improve our operations and services;

Ensuring that quality standards are maintained and improved by active monitoring, reviewing and improving all activities; and

Communicating this policy to our staff, including all of our agents.

The role of Quality Coordinator within will be performed by .

The Quality Policy Statement is issued under the authority of and approved by the < Business Owner or Designated Senior Manager> on the effective date.

Effective Date: dd-Mmm-200y

Our quality management system (QMS) is periodically reviewed to maintain compliance with the Transport Canada Accreditation Requirements.

Implementation of our quality management system (QMS) is the responsibility of all management and staff, including agents administering tests and agents performing other business functions within the scope of the QMS. This includes temporary and one-time agents. The development and maintenance of the quality management system (QMS) including the preparation and the approval of the Quality Manual is the responsibility of the .


Document No xx POLICIES AND PROCEDURES

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B POLICIES AND PROCEDURES The Quality Manual includes the policies and supporting procedures for quality management system (QMS).

1. Quality Management System The purpose of the quality management system (QMS) is to ensure that all services satisfy client expectations, adhere to Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements and have been delivered under controlled conditions.

performance and QMS effectiveness will be assessed in several ways:

By a program of planned internal audits, covering all aspects of the operation of the QMS;

By regular management reviews of the suitability and effectiveness of the QMS; By analysis of potential problems and non-conformances as indicated by client

and Transport Canada feedback and complaints; and By independent external audits, covering all aspects of the operation of the QMS.

1.1 Documentation Requirements Specific documentation is required to implement your quality management system (QMS) and to reflect what your organization does to deliver and assure the quality of your Course Provider services. To ensure the effective planning, operation, control and continual improvement of your QMS, the following must be documented: (Note: Appendix C provides a Documentation Checklist) A Quality Policy Statement (included in this document); A Quality Manual (this document), Procedures and documents required to ensure compliance with the Transport

Canada Pleasure Craft Operator Competency Program - Accreditation Requirements including the Transport Canada approved Test Protocol and a Boating Safety Course Manual and/or Study Guide prepared in accordance with the Pleasure Craft Operator Program Boating Safety Test Syllabus;

Records required as part of your accreditation (e.g., client records, internal audit reports, corrective actions, etc.);

Records required to demonstrate conformance to and effective operation of your QMS; and

Records required to manage, to operate and to administer your Course Provider services.

The documentation medium employed must be specified. The documentation medium used can be paper, magnetic, electronic, photograph, or a combination thereof.



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has implemented and maintains a documented quality management system (QMS). It is applicable to the services delivered in support of the Transport Canada Pleasure Craft Operator Competency Program and all activities and functions in which is involved and undertakes in support of services and administration of our quality program. All policies and procedures are documented to the extent necessary to enable to ensure and assure the quality of our services.

documented QMS includes:

A Quality Policy Statement (included in section A of this Manual); A Quality Manual and procedures (included in this Manual); A Transport Canada approved Test Protocol (separate document); Boating Safety Course Manual and/or Study Guide prepared in accordance with

the Pleasure Craft Operator Program Boating Safety Test Syllabus (separate document);

Records (included in section 1.1.3 of this Manual); and .

will make QMS documentation available. is subject to the requirements of the Provincial/Territorial Access to Information and the Privacy Act when responding to requests for documents and records.

1.1.1 Quality Manual The Quality Manual describes your organizations quality management system (QMS). It is a reference document which provides the outline of your quality management system (QMS) and describes how each element of QMS is met and maintained. The scope of the QMS includes only those activities and functional areas that are subject to your QMS for accreditation purposes. The Quality Manual must be reviewed periodically (at least once per year) to ensure its currency, continuing suitability, adequacy and effectiveness.

The Quality Manual is a policy document, containing details of how addresses the requirements of Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements, delivering and assuring quality Course Provider services. Quality Policy and direction for is determined by . The Quality Manual contains Quality Policy Statement and provides information on the procedures and operation of the quality management system (QMS).

In smaller organizations, the Business Owner may choose to perform the role of Quality Coordinator if there is not sufficient staff or expertise. Therefore, the Quality Manual could be maintained by the Business Owner and not the Quality Coordinator. The Quality Manual is accessible to staff members, including all agents and/or auditors. Amendments to the Quality Manual are also published and controlled by the Business Owner. Do revise the following two (2) paragraphs as appropriate for your organization.



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Staff members and agents will have access to of the Quality Manual. A paper-based master copy of the Quality Manual is maintained by the Quality Coordinator, who ensures that the electronic version is kept in alignment with its contents.

The Quality Manual will be reviewed periodically as part of the management review, at a minimum of once per year, by to ensure its currency, continuing suitability, adequacy and effectiveness. Amendments to the Quality Manual are controlled and published by the Quality Coordinator. Changes in content will be approved with the management and functions responsible for their implementation. The holders of paper-based Quality Manuals are responsible for incorporating authorized amendments and disposing of obsolete pages.

1.1.2 Control of Documents A system for generating, reviewing, approving, numbering, issuing and changing documentation, including paper and/or electronic media is required to comply with the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements. Therefore, in order to comply with Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements, QMS documents must be controlled. The control of documents means that any applicable internal document is accessible and available to whom it applies and available at the required point(s) of use. In addition, control means that the document: has been approved for adequacy prior to issue; has been reviewed, and updated as necessary, and re-approved prior to reissue; has its changes and current revision status identified; and remains legible and readily identifiable. In addition: applicable documents of external origins are identified and their distribution

controlled; and obsolete documents retained for any purpose are clearly identified and kept in a

secure location to avoid unintended use. In order to be compliant with this, internally controlled documents must also contain the following components: Title; Document number; Revision history; Version/revision number; Issue date, Responsible authority/document owner; Approved by; and Pagination.



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Detailed records of changes to controlled documents, including the reasons for the change, may be retained, rather than retaining actual copies of each issue of every document. A master list of controlled documents that records their level of approval, distribution, and revision status, including current or obsolete status must be maintained in order to manage all documents and demonstrate adherence to this requirement.

will control the following documents:

Quality Policy Statement; Quality Manual; Transport Canada approved Test Protocol (separate document); Boating Safety Course Manual and/or Study Guide prepared in accordance with

the Pleasure Craft Operator Program Boating Safety Test Syllabus (separate document);

Transport Canada supplied materials, such as policies, templates, reference documentation, Boating Safety Course Syllabus, and tests;

Copy of Competency of Operators of Pleasure Craft Regulations; and

In smaller organizations, the Business Owner and/or their designate is responsible for the maintenance, editing, numbering, approving, distribution, and communication of all new and revised quality management system (QMS) documentation. Do revise the following paragraph as appropriate for your organization.

Quality management system (QMS) documentation will be reviewed and approved by the prior to distribution and use. The Quality Coordinator ensures all QMS documentation amendments are made, reviewed, approved, identified, and communicated throughout .

Where applicable, changes and modifications to QMS documentation will be identified in the document through:

Document Number; Revision History; Version/Revision Number; Issue Date; and/or Highlighted text, within the document.

will use a master list to register all QMS documentation to track the current version/revision of documents, and thereby prevent the distribution and use of obsolete documents. All documents issued have an issued date and revision status indicated on the document. All staff members will be required to use and refer to current versions/revisions of these documents in performing their duties.

Staff receiving important new or revised documents from Transport Canada Pleasure Craft Operator Competency Program will be required to make them available to appropriate members of staff, and ensure that obsolete material is updated, withdrawn or destroyed. If retained, obsolete Transport Canada supplied materials will be suitably



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identified to prevent their inadvertent use. All obsolete copies are promptly removed from their point of issue or use. Obsolete Transport Canada supplied materials will be identified as Obsolete and filed for accreditation purposes or future reference.

Staff members, including agents administering tests and agents performing other business functions, will be held accountable for the control of documents they generate and/or use in the course of their duties.

1.1.3 Control of Records Records are a special type of document. Records are developed and/or accumulated as a result of activities performed and procedures executed related to the effective planning, operation, control and continual improvement of your quality management system (QMS). Records are required to demonstrate compliance with the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements, the quality of your organizations provision of Course Provider services, and the effectiveness of your quality management system (QMS). Records must also be controlled. Record retention times and disposition must be a minimum of four (4) years or until the next external audit, related to accreditation renewal, in order to demonstrate compliance with the Accreditation Requirements. Appendix D to this Quality Manual provides a Required Records Checklist.

maintains such records as are necessary to demonstrate the quality of its provision, compliance with the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements and Test Protocol, and the effectiveness of the quality management system (QMS).

controls the following records:

Internal audit reports including completed QMS Self-Assessment Checklists (latter found at Appendix B to this Quality Manual);

External audit reports; Results of Test Protocol Inspections, Reviews, Spot Checks; Corrective actions; Preventive actions; Management review minutes and follow-up minutes; Cardholder information; Course Provider records (e.g., Course Provider Identifier, Course Provider Name,

Date/Time/Location of Test, candidate participants list); Client feedback; .

Staff members, including agents administering tests or agents performing other business functions, will be responsible for ensuring that the records for which they have responsibility are clearly labeled or otherwise identified, legible and readily retrievable. Records are required to be stored in ways that minimize the risk of their deterioration or loss. Paper records must be maintained in compliance with Privacy Act.



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Cardholder records and other records containing personal and confidential information will have controlled access to secure storage in compliance with the requirements of the Provincial/Territorial Access to Information and the Privacy Act and Personal Information Protection and Electronic Documents Act. Access to these records is restricted to designated staff members who generate and/or use these records in the course of their duties.

Paper records will be maintained in compliance with the requirements of the Provincial/Territorial Access to Information and the Privacy Act , where applicable.

All records will be retained for a minimum of four (4) years or until the next external audit. The disposal of all records shall be performed in accordance with normal business practice (e.g., recycling or shredding) unless stipulated according to contractual or accreditation requirements and applicable Provincial/Territorial Privacy Acts. At that time the records will be reviewed by the Quality Coordinator and either destroyed or maintained for a specified timeframe.

Staff members, including all agents, will be held accountable for the control of records.

Internal audits serve to ensure that the necessary records are being generated, utilized and retained.

1.1.4 Record Submissions to Transport Canada The Business Owner or Designated Senior Manager must regularly provide, maintain and send electronic client records to Transport Canada as part of the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements. Information that must be entered into the Transport Canada Pleasure Craft Operator Database System includes, but is not limited to, the following: Card Number; Pleasure Craft Operator Name; Pleasure Craft Operator Date of Birth; Complete Mailing Address Course Provider Name; Date Original Pleasure Craft Operator Card Issued; and Other information to be determined.

At the completion of each test cycle, will enter client information required by the Transport Canada into the Transport Canada Pleasure Craft Operator Database System (PCODS). Information submitted includes, but is not limited to the following:

Card Number; Pleasure Craft Operator Name; Pleasure Craft Operator Date of Birth; Complete Mailing Pleasure Craft Operator Address; Course Provider Name; Date Original Pleasure Craft Operator Card Issued; and



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Other information to be determined. will adhere to all Transport Canada policies, processes, procedures and guidelines relating to the database use and operation.



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2. Management Responsibility Preface to Management Responsibility In smaller organizations, the responsibilities should be adjusted throughout this section and the entire Quality Manual to reflect the actual duties within your organization. For each subsection, follow the guidance provided in prefaces (all text in blue in explanation boxes) to assist you in customizing it to your organizations size.

2.1 Management Commitment The Business Owner, Designated Senior Manager and/or senior management must actively support and promote the need to meet Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements within your organization. In addition to meeting the accreditation requirements, benefits of the Management commitment for your organization could include: the improvement of satisfaction levels of your clients obtained through a client focus approach; achievement of your business goals obtained with regular management reviews; and, leadership provided by your continuous involvement.

The is committed to:

Having a documented quality management system that satisfies the requirements as outlined in the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements;

Meeting and exceeding our accreditation commitments; Implementing, following and pursuing a quality management system (QMS) that

fosters a quality culture across the organization and supports continuous improvement; and

Working with our clients and Transport Canada to monitor our success and to continuously evolving and improving our operations and services.

demonstrates our commitment by:

Communicating to the organization the importance of meeting and exceeding Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements;

Establishing, employing and continually improving our stated Quality goals; Conducting regular management reviews and internal audits to identify

opportunities for improvement; Establishing mutually beneficial relationships with Transport Canada; Regularly communicating with clients about our Course Provider services; and Performing and participating in external audits.

In addition to this commitment by management, all staff are encouraged to seek ways to continually improve practices and services provided to our clients through Corrective Action and Preventive Action.



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2.2 Roles, Responsibilities and Authorities The Business Owner or Designated Senior Manager must ensure that the roles, responsibilities and authorities for delivering and administering Course Provider services and providing quality assurance are defined and communicated within your organization. The duties of key staff who manage, perform and verify work affecting the quality of Course Provider services must be described. An organizational chart delineating the interrelation of staff must be presented. Staff members include all agents administering tests and all agents performing other business functions, including temporary or one-time agents. Benefits of the definition of roles, responsibilities and authorities for your organization will be the effective performance of your QMS and the assurance that everyone is responsible for the delivery of quality client services. The depth of the description of the roles, responsibilities and authorities is dependant on the organization size.

Preface to Organizational Chart Example This example Organizational Chart is intended to serve as a tool to guide you in the development of your organizational chart. This example represents the possible minimum functions of an organization. For smaller organizations several management functions may be performed by the same manager and for larger organization, two or more management levels may be described. Your organizational chart and associated roles and responsibilities may be more detailed.

Staff

Business Owner

Quality Coordinator



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2.2.1 Business Owner or Designated Senior Manager Preface to Responsibilities Business Owner or Designated Senior Manager In smaller organizations, the Business Owner or Designated Senior Manager may perform the duties of the Quality Coordinator, except where job conflicts may exist. As appropriate, the responsibilities of the Business Owner and Quality Coordinator should be adjusted throughout this section and the entire Quality Manual to reflect the actual duties within your organization. This section contains specific duties/accountabilities/responsibilities as examples only. Create your own duties/accountabilities/responsibilities based on your organization or use the provided descriptions as appropriate for your organization.

The Business Owner or Designated Senior Manager is:

Accountable for the quality management system (QMS);

Responsible for the coordination of overall quality management for ;

Accountable for the development and revision of the Quality Policy Statement; Accountable for the review and approval of any revision of this Quality Manual

once each year; Accountable for the performance of a management review at least once each

year, except where job conflicts exist; Acts as Chair for the annual management review meeting; Responsible for assuring that the Quality Coordinator has the authority and

organizational freedom to perform the duties listed in section 2.2.2; Accountable for the ensuring the creation, submission, retention and storage of

records; Responsible for participating in internal audits, except where job conflicts exist; Accountable for scheduling external audits and liaising with qualified person

external to the Course Providers organization; Participating in external audits; Responsible for liaising with Transport Canada on all test service and quality

related matters; Accountable for development and maintenance of communications channels

and arrangements with Clients, Transport Canada, qualified person external to the Course Providers organization conducting external audits and staff, including agents administering tests and agents performing other business functions;

Accountable for the prevention from damage and for identification, preservation, storage, handling, and use of Transport Canada supplied tests/documents/ materials while the tests/documents/materials are in the s possession;

Responsible for approving use of Transport Canada supplied materials upon resolution of damage, loss, or problems;

Responsible for reporting any damage, loss, or problems found to Transport Canada supplied materials;



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Accountable for submitting client records to Transport Canada and entering client information into the Transport Canada Pleasure Craft Operator Database System (PCODS);

Accountable for communicating the importance of and ensuring staff awareness, including Agents, of meeting and exceeding Transport Canada accreditation commitments and QMS requirements;

Responsible for demonstrating and providing objective evidence of management commitment;

Accountable for developing, implementing, maintaining and ensuring the organization follows our Test Protocol in compliance with the Competency of Operators of Pleasure Craft Regulations;

Responsible for the overall performance of internal audits to meet the Quality Policy and quality management system (QMS) requirements;

Accountable for the review of the Quality Manual; and .

2.2.2 Quality Coordinator Preface to Responsibilities Quality Coordinator In smaller organizations, the Business Owner or Designated Senior Manager may perform the duties of the Quality Coordinator, except where job conflicts may exist. As appropriate, the responsibilities of the Business Owner and Quality Coordinator should be adjusted throughout this section and the entire Quality Manual to reflect the actual duties within your organization.

The Quality Coordinator is:

Responsible to the Business Owner or Designated Senior Manager for managing the quality management system (QMS);

Responsible for ensuring the review and control of this Quality Manual; Responsible for ensuring the control of non-conformances; Responsible for the performance of internal audits, except where job conflicts

exist; Responsible for the preparation and control of corrective actions, as applicable; Responsible for the preparation and control of preventive actions, as applicable; Responsible for reviewing corrective actions monthly; Responsible for monitoring of the quality program, and reporting regularly to the

Business Owner on its effectiveness; Responsible for assuring that the policies in this Quality Manual are followed for

all work performed under the scope of this manual; Responsible for escorting qualified persons external to the Course Providers

organization for the purpose of these external persons conducting external audits;

Responsible for participating in management reviews and maintaining review meeting minutes/follow-up minutes;



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Responsible for providing information and materials for input into management reviews;

Responsible for ensuring that the records for which they have responsibility are clearly labeled or otherwise identified, legible, readily retrievable, and stored in ways that minimize the risk of their deterioration or loss;

Accountable for controlling of Quality Assurance and QMS records; Responsible for controlling of this Quality Manual; and .

2.2.3 All Staff All staff members, including agents administering tests and agents performing other business functions, are:

Individually responsible for the level of quality in the work they perform and services they deliver;

Responsible for making available important new (e.g., Transport Canada supplied regulations or policies) or revised documents from Transport Canada Pleasure Craft Operator Competency Program to appropriate staff members, including agents;

Responsible for ensuring obsolete Transport Canada Operator Competency Program and materials/documentation is updated, withdrawn or destroyed;

Responsible for ensuring Transport Canada supplied materials retained are suitably identified to prevent unintended use;

Accountable for controlling all documents and records used in performing their duties;

Responsible for using current versions/revisions of documents in performing their duties;

Identifying opportunities for continual improvement of practices and services provided to our clients through Corrective Action and Preventive Action;

Responsible for incorporating authorized amendments and disposing of obsolete pages of paper-based Quality Manuals, if applicable;

Responsible for the prevention from damage and for identification, preservation, storage, handling, and use of Transport Canada supplied tests/documents/materials while the tests/documents/materials are in the s possession;

Performing verification of Transport Canada supplied materials; Responsible for following our Approved Test Protocol in compliance with the

Competency of Operators of Pleasure Craft Regulations; Participating in staff orientation and awareness sessions; and



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2.3 Management Review A Management Review is a routine review of the overall status and performance of your organizations quality management system (QMS) and the services that are provided. Management Reviews provide an opportunity for Business Owners and Senior Management to consolidate and review a variety of information and input, including but not limited to internal audit results, and, to assess/evaluate the overall state of their quality management system (QMS) and to identify where improvements can be made. The Business Owner and/or Senior Management is/are required to review your organizations quality management system (QMS), at planned intervals, to ensure its currency, continuing suitability, adequacy and effectiveness. This will enable them to monitor the effectiveness of your quality management system (QMS), to ensure its continuing suitability in meeting client expectations, and ensure that the Quality Policy Statement and quality procedures and practices are being met. Preparation for your Management Reviews will include the gathering of the information and input; analysis of the information and input; some form of documentation of the results; and the outputs or actions resulting from the Management Review. Management Reviews should be conducted when it is appropriate for your organization to do so, which could range from every week, to every quarter to a minimum of once per year. Management Reviews can take the form of a face-to-face meeting with minutes and follow-up minutes; or, a conference call with minutes and follow-up minutes; or, the development of a written report. Management Review outputs could include, but are not limited to, actions to improve your organizations QMS and/or actions to improve your organizations services. Management reviews must include assessing opportunities for improvement and the need for changes to the QMS (e.g., changes in the business, suggestions from staff/agents, changes to accreditation requirements, Test Protocol Inspection/Reviews/Spot Check non-conformances). All records from Management Reviews (e.g., formal reports, meeting minutes and follow-up minutes) must be maintained. Regardless of the form (report, meetings, conference calls etc), your Management Review must include an overview and description of your quality management system (QMS) performance, including internal and external audit results, non-conformances found, status of corrective and preventive actions, results of Test Protocol Inspections, etc. The Management Review and outputs must be communicated and/or circulated within your organization to ensure that all staff/agents are aware of the overall status and performance of your QMS. Records of staff attendance and comments provided at Management Review meetings must be maintained. In addition, records of the distribution of Management Review reports and any comments received must be maintained. The original Management Review report must be maintained in your records. Do revise the following three (3) paragraphs as appropriate for your organization.



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Management Review meetings will be conducted in the form of regular meetings. Management and other designated staff will meet to review the currency, continued suitability, adequacy, and effectiveness of the quality management system (QMS) and compliance with the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements. Review meetings will be chaired by the < Business Owner or Designated Senior Manager>and must be attended by all staff/agents.

Management Review meetings will be conducted in the form of a formal report. Management and other designated staff will prepare the Management Review report to review the currency, continued suitability, adequacy, and effectiveness of the quality management system (QMS) and compliance with the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements. The Management Review report will be signed off by the < Business Owner or Designated Senior Manager> and distributed to all staff/agents for information and/or comment.

s Management Review items will, as a minimum, include the following:

an overview and description of your quality management system (QMS performance;

internal and external audit results;

Test Protocol Inspection/Review/Spot Check results;

non-conformances found;

status of corrective and preventative actions;

review of opportunities for improvement;

the need for changes;

an opportunity for staff feedback/comment;

decisions/specific actions to improve s QMS and/or services; and

.

To accomplish these reviews, management will collect and evaluate:

Internal and external audit results; Review of Quality Manual; Information on client and Transport Canada feedback, including complaints; Results of Test Protocol Inspections, Reviews, Spot Checks; Status of preventive and corrective actions; Follow-up actions from earlier management reviews; Planned change(s) that could affect the QMS; and Recommendations for improvement.



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The Quality Coordinator will maintain the Management Review , , all staff/agents comments and feedback and any management decisions detailing actions and decisions related to:

Compliance with the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements;

Improvement of the effectiveness of the QMS and its processes; Improvement of the processes and services relative to accreditation

requirements; and Resources needed to effect improvement.

Necessary Corrective Action and Preventive Action will be initiated, if required, in accordance with the processes and procedures in sections 4.8 and 4.9.



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3. Delivery of Course Provider Services

3.1 Official Language The Business Owner or Designated Senior Manager must ensure that all Course Provider services, including the administration of the course, where applicable, the administration of the test, all verbal or written communications or correspondence concerning the services, the test, and the Pleasure Craft Operator Card are provided in the official language(s) (French or English) as advertised by the Course Provider. Course Provider services must be in compliance with the requirements on official languages section XXX of the Competency of Operators of Pleasure Craft Regulations.

will ensure that the following services are provided in the official language(s) () as advertised:

The administration of the course; The administration of the test; All verbal or written communications and correspondence concerning the

services; The test; and The issuance of the Pleasure Craft Operator Card.

Internal audits serve to ensure that client services provided by agents administering tests and agents performing other business functions, are being offered in the official language(s) as advertised.

3.2 Client Communication The Business Owner or Designated Senior Manager must accurately reflect and fully disclose all information consistent with the Competency of Operators of Pleasure Craft Regulations. The Business Owner or Designated Senior Manager must also ensure that effective two-way communication channels and arrangements with clients in regards to its Course Provider services (such as communication of test results and issuance of Pleasure Craft Operator Card, contacts, enquiries, client feedback, including client compliments and complaints) are implemented. Do revise the bulleted list as appropriate to your organization.

will ensure that the following communications channels and arrangements are established with our clients as necessary:

A dedicated business contact name, address and telephone number; An electronic mail system; A business web site, containing Course Provider services and contact

information, as well as frequently asked questions; A link to Transport Canada Office of Boating Safety web site; Printed materials, such as course calendars and flyers; Information provided is accurate and up-to-date;



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All communications are consistent with the Regulations and provide full disclosure; and

3.3 Transport Canada Communication The Business Owner or Designated Senior Manager must ensure effective two-way communication channels and arrangements with Transport Canada in relation to accreditation requirements, such as access to the Transport Canada Pleasure Craft Operator Database System (PCODS); handling of enquiries; and handling of Transport Canada feedback, including how any Transport Canada concerns and complaints will be addresses/implemented.

will ensure that the following communications channels and arrangements are established with Transport Canada as necessary:

Face-to-face communications via telephone, email and one-on-one meetings (e.g., reporting of problems with Transport Canada supplied tests);

Transport Canada Pleasure Craft Operator Database System (PCODS); Test Protocol Inspections and discussions; Communication of internal audit results and QMS documentation at the request

of Transport Canada; Communication of external audit results and QMS documentation; and

3.4 Transport Canada Supplied Materials Transport Canada will maintain three (3) different tests, in both official languages, that will be provided to Course Providers annually. The Business Owner or Designated Senior Manager must implement effective measures for identifying, verifying, protecting and safeguarding Transport Canada tests and any associated documents/materials (e.g., policies) provided related to test administration and the organizations Course Provider services. These measures must include access controls to tests either downloaded from the Pleasure Craft Operator Database System (PCODS) (control of login user ID and password) or on CD (restricted access to file cabinets of hardcopies of tests). The verification of current applicable versions of tests will be performed as a part of Control of Documents process (section 1.1.2). The suitability of the tests/materials provided by Transport Canada for incorporation into courses and/or testing must determined before use. Staff members must verify such tests/documents/ materials before use. The Business Owner or Designated Senior Manager must report any damage, loss, or problems found to Transport Canada. Records of tests/documents/materials that are lost, damaged or otherwise unsuitable for use are maintained.

The suitability of tests and any associated documents and materials provided by Transport Canada for incorporation into courses and/or test events is established before any course and/or test is provided. Such tests/documents/materials will be reviewed and verified by before use, and any deficiency, damage, loss or



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problem found will be reported immediately to Transport Canada. Records of the deficiency/damage/loss/problem will be documented, including the following:

Test/Document/Material identification; Date the test/document/materials delivered; Name or initials of the person who verified the test/document/material; Indicator of the test/document/materials being compliant; Description of the deficiency/damage/loss/problem; Date the deficiency/damage/loss/problem reported to Transport Canada; Date and description of the resolution; Approval of the Business Owner or Designed Senior Manager upon evaluation

completion; and Ensure correct versions of tests are incorporated for use into the day-to-day

operations and provision of services.



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4. Measurement, Analysis and Improvement

4.1 Client Satisfaction The Business Owner and/or senior management must monitor client satisfaction levels for all of your Course Provider services. Client satisfaction is one measure of the performance of your organizations quality of delivery of Course Provider services and quality management system (QMS). Client satisfaction is the clients perception of the degree to which his/her expectations have been met.

will measure and monitor information relating to our clients level of satisfaction as to whether we have met their expectations and delivered quality Course Provider services. This is accomplished by:

Client debriefs at end of or subsequent to a test; Course/test evaluation summaries, as appropriate; Client feedback compliments and complaints; Transport Canada feedback, Course Provider Monitoring results, Transport

Canada audits; Discussions with staff, including agents, administrative

staff, call centers/phone staff; and

The will ensure that information is collected and/or reported by staff members and is analyzed and considered in the s planning activities for future Course Provider services and opportunities for improvement of the QMS, including Transport Canada approved Test Protocol.


4.2 Transport Canada Accreditation Requirements Your organization must comply with the Transport Canada Accreditation Requirements specified in the Competency of Operators of Pleasure Craft Regulations. The Business Manager or Designated Senior Manager must ensure that these regulatory requirements are understood and met within your organization. The Transport Canada Pleasure Craft Operator Competency Program Accreditation Requirements Document provides detailed information and tools to assist Course Providers in understanding how to meet these regulatory requirements.

is committed to ensuring that the Competency of Operators of Pleasure Craft Regulations and Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements are met with the aim of enhancing both client and Transport Canada satisfaction. This will be accomplished by:



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Committing to a quality management system (QMS) that satisfies the requirements as outlined in the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements;

Implementing and using a Transport Canada approved Test Protocol; Implementing and using a Boating Safety Course Manual and/or Study Guide

prepared in accordance with the Pleasure Craft Operator Program Boating Safety Test Syllabus;

Providing on-going staff orientation and awareness on: - The Quality Policy Statement; - The Competency of Operators of Pleasure Craft Regulations; - The ; - The Transport Canada Pleasure Craft Operator Competency Program -

Accreditation Requirements; - The quality management system (QMS);

Establishing effective two-way communication channels and arrangements with clients as well as Transport Canada;

Focusing on continuous improvement to ensure value for , clients and Transport Canada;

Working with Transport Canada to monitor our success in delivering our Course Provider services; and

. To this end, performance and QMS effectiveness is assessed in several ways:

By a program of planned internal audits, covering all aspects of the operation of the QMS;

By regular management reviews of the suitability and effectiveness of the QMS; By analysis of potential problems and non-conformances as shown by client and

Transport Canada feedback and complaints; By Test Protocol reviews/inspections/spot checks; and By independent external audits, covering all aspects of the operation of the QMS.

4.3 Client Feedback Client feedback, including compliments and complaints, is an indicator of client satisfaction with your Course Provider services, and in turn the performance of your organizations quality management system (QMS). Client feedback is especially important when client expectations and/or requirements have not been met. Complaints must be handled immediately by staff members and/or escalated to the Business Owner or Designated Senior Manager, as appropriate. All complaints (and their resolutions) must be formally documented and controlled as records. The benefits of client feedback for your or organization are to create a positive environment based on your client focus experience and your strong commitment to



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client service and, therefore, contribute to the retention of existing clients and to the attraction of new clients.

Clients may at any time lodge a formal complaint, express any concerns or dissatisfaction to staff. At the test site, staff members, including agents administering tests, temporary or one-time agents, are encouraged to try and solve any client concerns themselves or direct the client to another staff member who may be more appropriate for handling a particular concern. Concerns that cannot be resolved by staff are directed to the for immediate handling.

Clients can submit a suggestion, comment, compliment, or concern regarding any information or service provided by by contacting through any of our client communication channels and arrangements. All submissions received are directed to the to review and resolve, if necessary.

All complaints will be formally documented and their resolution recorded by the in a complaint log. For each complaint, the following information will be identified:

An identification number for reference and tracking purposes; A clear and concise written description of the complaint; The source of the complaint; and A description of the action taken to resolve the complaint.

Positive client feedback/compliments may be compiled locally to assist in documenting lessons learned etc.


The will ensure all staff members are notified of the complaint, resolution and/or corrective action/preventive action taken in order to prevent recurrence.

4.4 Transport Canada Feedback Any and all feedback received from Transport Canada, including compliments and complaints, is an indicator of Transport Canada satisfaction with performance your organization and adherence to the Competency of Operators of Pleasure Craft Regulations and Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements. All requests and/or feedback from Transport Canada that pertain specifically a Course Providers adherence to the Competency of Operators of Pleasure Craft Regulations or that indicate overall satisfaction or dissatisfaction with some aspect of the Course Providers service, including compliments and complaints from the public must be documented. This may include compliments and complaints received in person or by written correspondence, emails and phone calls. Transport Canada feedback is especially important when regulatory and accreditation requirements have not been met.



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All requests and/or feedback, including Client compliments and complaints, received from Transport Canada to will be formally documented and received through the results of Transport Canada Test Protocol verification, Transport Canada Audit results, and accreditation monitoring. All feedback received must be directed to the to review and resolve. Any resolutions to complaints must be implemented in compliance with both regulatory and accreditation requirements, processes and procedures.


4.5 Internal Audit Internal audits must be planned and scheduled to encompass the elements of the quality management system (QMS) as defined in your Quality Manual. Planning and scheduling can consist of the following activities: performing a full annual audit of the QMS; or performing several partial or process audits that focus on specific activities or functions covering the entire QMS; and performing follow-up audits to verify and assess the corrective action taken as a result of a previous system or process audit. Audits must be performed by staff independent (i.e., having no direct line of responsibility for the activity or area being audited) of the activities and functional areas being examined to ensure objectivity and impartiality of the audit process. Auditors must not audit their own work. The Quality Coordinator is normally responsible for performing audits. In smaller organizations, the Business Owner or Designated Senior Manager may perform the internal audits and have a senior management team member or designated staff member review the activities s/he is responsible for. Additionally, a qualified person external to the organization may be secured to perform the internal audit. A combination of Test Protocol inspections, reviews and spot checks of management and staff, including agents administering tests and agents performing other business functions, must be planned, scheduled and conducted on an annual basis. This includes temporary or one-time agents. To achieve and maintain accreditation, twenty-five (25) percent of agents administering tests and twenty-five (25) percent of agents performing other business functions must be audited, inspected/reviewed/spot checked, annually as applicable, based on the respective average number of agents per fiscal year. For those organizations having less than four (4) staff, including agent(s), the Course Provider shall schedule and perform audits and test protocol inspections/reviews/spot checks for a minimum of one (1) agent administering tests and a minimum of one (1) agent performing other business functions annually. Please refer to the Pleasure Craft Operator Competency Program - Internal Audit Guide for Course Providers for specific details and guidance. The QMS Self-Assessment Checklist, found at Appendix B to this Quality Manual, is a useful tool to assess overall accreditation readiness and in preparing for audits. Records from internal audits (e.g. completed QMS Self-Assessment Checklists, original audit report, follow-up audit report, completed audit checklists) must be maintained. Internal audit results are required to be maintained as Transport Canada reserves the right to request documentation in order to verify that the conditions for accreditation continue to be met. In exceptional circumstances, as indicated in Section 8.2 of the Transport Canada Pleasure Craft Operator Competency Program Accreditation



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Requirements document, Transport Canada may perform a Transport Canada Audit anytime throughout the accreditation period.

The operation of the s quality management system (QMS) will be audited internally at least once per year to determine its adequacy and effectiveness, and to verify staff compliance with policies and procedures. All management and staff, including agents administering tests and agents performing other business functions, will be audited, inspected, reviewed and/or spot checked, as applicable, for compliance with the Transport Canada Pleasure Craft Operator Competency Program requirements and delivery of Course Provider services as outlined in section 3.0 of this Manual. To achieve and maintain accreditation, twenty-five (25) percent of agents administering tests and twenty-five (25) percent of agents performing other business functions will be audited, inspected/reviewed/spot checked, annually as applicable, based on the respective average number of agents per fiscal year.

The Quality Coordinator develops and maintains a schedule of internal audits. Internal audits are scheduled for each activity and functional area within the scope of the QMS. Activities to be audited include:

Control of documents; Control of records; Records submissions to Transport Canada; Management commitment; Management review; Transport Canada supplied materials; Test Protocol; Client satisfaction and feedback; Transport Canada requirements and feedback; Internal audits; Control of non-conformances; Corrective action; and Preventive action.

Functional areas to be audited will include, at a minimum:

Preface to Responsibilities Functional Areas All roles, responsibilities and authorities specified in your organizational chart and section 2.2 of your Quality Manual must be identified and audited.

Business Owner or Designated Senior Manager; Quality Coordinator; Agents performing test administration activities; Agents performing other business functions; and Other Staff, where appropriate.

The schedule will take into account the status and importance of the activities and functional areas to be audited. The audits may be conducted by the Quality Coordinator,



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Business Owner, or qualified external person (i.e., having no direct line responsibility for the activity or functional area being audited) of the activities and functional areas being examined. When a qualified person external to our organization is employed, the is accountable and responsible for the audit and audit results of the internal audit.

During the internal audits of the QMS, the Quality Coordinator, Business Owner, or designated qualified person external to our organization will examine objective evidence (e.g., records) and make findings on:

Compliance to applicable policies and procedures; Weaknesses in existing policies and procedures; and Inefficiencies in actual practices.

The Quality Coordinator, Business Owner, or designated qualified external person will submit audit reports which include action items to correct weaknesses or non-conformances. Each action item will be assigned to a specific individual and will have a date specified by which the preventive or corrective action should be complete. The Quality Coordinator, Business Owner, or designated qualified external person may make recommendations for the resolution of weaknesses in policies and procedures and inefficiencies in practices.

Auditees are required to take timely post-audit corrective action. Follow-up audit activities will be arranged by the Quality Coordinator, Business Owner, or designated qualified external person to verify corrective action has been taken, and record the implementation and effectiveness of corrective action. Sufficient time will be allowed for corrective action and is determined by the Quality Coordinator, Business Owner, or designated qualified external person based on the seriousness and impact on service quality and in accordance with the guidance provided in the Transport Canada Pleasure Craft Operator Competency Program - Internal Audit Guide for Course Providers.

Activities or functional areas showing repeated non-conformances will be audited more frequently until the non-conformances are corrected. Internal audits will be conducted using an internal audit report form, checklists, and/or procedures by the auditor.

The original audit report will be kept in controlled files. Copies will be distributed to the and audit participants.

The results of all internal audits will be reviewed by the Quality Coordinator, Business Owner or Designated Senior Manager and raised as an agenda item at management review meetings or in management review reports. Additionally, internal audit results, including completed corrective action, must be retained by the as Transport Canada reserves the right to request documentation in order to verify that the conditions for accreditation continue to be met.

4.6 External Audit The external audit is a key element in assuring that your Course Provider services are being provided in compliance with the Competency of Operators of Pleasure Craft



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Regulations and Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements, and in a consistent and controlled manner. External audits must be performed by a qualified person external to your organization and include the conduct of a full system audit of your quality management system (QMS) to the requirements of this Quality Manual and associated documentation. An external audit of your QMS is required as part of initial accreditation. External audits are also part of the on-going Transport Canada accreditation program and must be performed every 4 years from initial accreditation in order to support accreditation renewal. Follow-up audits, re-audits and/or extraordinary audits are performed only if applicable.

An independent external audit conducted for our initial Transport Canada accreditation. Periodic external audits must be scheduled and successfully passed for accreditation renewal.

External audits will be performed every four (4) years to verify and assure that continues to meet the requirements of the Competency of Operators of Pleasure Craft Regulations and Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements and to assess the effectiveness of s quality management system (QMS).

In compliance with the Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements, for each audit, an audit report will be prepared by the qualified person external to our organization. Each report includes audit details, discussion of non-conformances and concerns identified, and conclusions reached by the auditor. Concerns and opportunities for improvement are also identified in the audit report, however they do not necessarily require a formal response from for corrective action.

If the qualified person external to our organization determines that is not in conformance with Transport Canada Pleasure Craft Operator Competency Program - Accreditation Requirements or our own policies and procedures, the qualified person external to our organization may give the opportunity to take correction, determine cause, and take corrective action within a period determined by the qualified person external to our organization without prejudice to right of immediate termination of accreditation. Evidence of implementation of acceptable correction and corrective action for all non-conformances is required before suspension of accreditation is removed by Transport Canada. The will be required to take timely post-audit correction and corrective action.



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4.7 Control of Non-conformances A non-conformance is the non-fulfillment of a requirement. When non-conformances occur during delivery of your Course Provider services, staff members must take immediate action to address and resolve the non-conformance immediately. Records of all non-conformances must be controlled and maintained. One example of a non-conformance is provided below and this example will be carried over to Section 4.8. Example of a non-conformance during a test protocol inspection, conducted in accordance with Section 2.2.2 of the Pleasure Craft Operator Competency Program Internal Audit Guide for Course Providers, the auditor observed that the agent administering the test did not collect and handle the information and records created before, during and after the test event in accordance with the established Test Protocol.

When possible, any non-conformance with regard to the provision of Course Provider services to s clients, will be dealt with by the staff or management member(s) or Business Owner who are directly involved. Staff members are required to identify, document, and take timely action to address, non-conformances that fall within the scope of the quality management system (QMS). Recommendations for corrective action for these non-conformances may be identified by the client, Transport Canada Inspectors, qualified persons external to the organization, staff or other parties as appropriate. Any staff member can initiate a corrective action, to address any non-conformance they become aware of.

Non-conforming services are corrected and subject to re-verification after correction to demonstrate conformance. Correction is undertaken immediately if the non-conformance is a result of a Test Protocol failure.

4.8 Corrective Action Corrective action is an action taken to correct and eliminate the actual cause of a procedure, service or product that has resulted in an identified non-conformance. Corrective action is directed at revising your organizations quality management system (QMS). Records of corrective actions are to be maintained. A corrective action is related to a non-conformance and is reactive. A corrective action includes an analysis of the cause of the non-conformance, the identification of a root cause, the development/implementation of the action to correct the non-conformance and ongoing monitoring to ensure that the corrective action was effective. An example of a Corrective Action carried over from Section 4.7 is provided below for clarification and guidance: non-conformance was identified and documented (as per Section 4.7); the root cause was identified in that this agent was hired at a particularly busy

period and although he/she did receive the requisite training/orientation, it appears as though one key staff member was not available for these training sessions and as a result training in this area was not completed;

in addition, it was discovered that three (3) other agents attended the same training sessions; and



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the corrective action is to reschedule this portion of the training for all four (4) agents and to monitor their performance on subsequent Test Protocol reviews and spot checks.

will take corrective action to eliminate the causes of non-conformances in order to prevent recurrence. Corrective actions are identified during internal and external audits, or as a result of formal client and Transport Canada complaints about a serious breakdown in s quality management system (QMS). Corrective action taken is appropriate to the effects of the non-conformances encountered.

The Quality Coordinator, Business Owner or Designated Senior Manager is responsible for coordination and administration of the corrective action effort and will take action as required to assure adequate corrective measures are being performed. All corrective actions will be recorded, controlled and tracked until resolution. For each corrective action, the following information will be identified:

An identification number for reference and tracking purposes; A clear and concise written description of the non-conformance requiring

corrective action; The source of the corrective action (e.g., audit identifier, title and date); The responsible manager; A description of the action taken to address the non-conformance, such as

describing and committing to who will do what by when to correct the problem and prevent its recurrence; and

The status of the corrective actions (e.g., where the action to address a corrective action has not been completed, the deadline is identified. Corrective actions that have been fully addressed are marked as closed.).

The Quality Coordinator, Business Owner or Designated Senior Manager will also ensure that follow-up on the progress of the corrective action effort and activities is completed by the target completion date and verifies that all corrective action activities are completed by the target completion date, and that the root cause of the problem has been eliminated.

Responsibility for undertaking the corrective action lies with the manager or agent responsible for the related procedure, service or product. For each corrective action, the manager or agent is responsible for:

Investigating the extent of the problem; Determining the root causes of the problem; Deciding on corrective action; Implementing the corrective action; and Initiating permanent changes in any related documentation (e.g., Quality Manual,

procedure, Test Protocol), if appropriate.



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The Quality Coordinator, Business Owner or Designated Senior Manager will review the completed corrective actions monthly.

4.9 Preventive Action Preventive action is an action taken to identify and eliminate the cause of a potential problem, undesirable event or non-conformance. Preventive action is directed at revising the organizations quality management system (QMS) in order to eliminate potential breakdowns or weaknesses and implement process improvement. Records of preventive actions are to be maintained. Preventive action is related to weakness of the QMS and is proactive. An example of a preventive action is provided here to assist with the understanding of this term. Example of a Preventive Action your organizations staff quality management system (QMS) orientation and training sessions were conducted prior to any client services being provided, however, due to no fault of your own, your computer system was not available for on-line demonstrations during the training sessions. In order to preclude any potential problems in preparing for and administering tests, in accordance with the established Test Protocol, a Preventive Action could be the scheduling of one-on-one training sessions for staff/agents and/or the assignment of someone with the requisite expertise to assist in the preparation and administration of initial test events.

The Quality Coordinator, Business Owner or Designated Senior Manager is responsible for coordination and administration of the preventive action effort and will take action as required to assure adequate proactive measures are being performed. All preventive actions will be recorded, controlled and tracked until resolution. Preventive actions are appropriate to the potential impact of the weakness.

For each preventive action, the following information will be identified:

An identification number for reference and tracking purposes;

A clear and concise written description of the potential problem (deficiency or non-conformity) requiring preventive action;

The source of the preventive action (e.g., audit identifier, title and date);

The responsible manager or agent;

A description of the action taken to address the weakness, such as describing and committing to who

2008 Nov Pcoc Qm Template

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