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Corrective Action Process

The corrective action process is a tool to identify and fix deficiences in a system that, if not corrected, may have a negative impact on project deliverables.

Identification of Quality System Deficiencies

  • A deficiency is defined as any unauthorized deviation from acceptable procedures or practices, a defect in an item, or failure to conform with a specified requirement.
  • Deficiencies may be identified during the course of a formal agency audit or internal audit. Deficiencies may also be self-identified during the course of routine work.
  • Deficiencies shall be documented immediately and reported to supervisory personnel in writing. This notification serves as the initial deficiency notice.
  • Supervisory personnel shall forward initial deficiency notices to the appropriate project manager and lead QA staff. The program’s Lead QA specialist will determine whether or not deficiencies are significant conditions. Project, program, and organizational managers may also determine whether deficiencies are significant conditions.
  • The Lead QA specialist shall notify affected Division Directors, Section Managers, Grant and Program Managers, and the QA Manager of any significant conditions.
  • If the Lead QA specialist and project, program, or organizational management disagree as to the determination of significant conditions for a deficiency, any of the parties may appeal to the TCEQ QA Manager for resolution.

Planning and Implementing Corrective Actions

  • Project managers (or designees) shall prepare a corrective action plan (CAP) to determine and document the following with regard to each deficiency:
    • root cause(s);
    • programmatic impacts;
    • required corrective action(s);
    • required corrective action(s) to prevent reoccurrence;
    • means by which corrective actions will be verified as effective;
    • means by which corrective action completion will be documented;
    • timetable(s); and
    • individual(s) responsible.
  • Within 30 days of the initial deficiency notice, the project manager (or designees) shall submit a copy of the CAP to supervisory and lead QA staff involved in implementing or monitoring corrective actions. The Lead QA specialist shall forward copies of CAPs concerning significant conditions to the appropriate TCEQ management.
  • Supervisory staff shall ensure CAPs are implemented effectively and in a timely manner. The Lead QA specialist may monitor the implementation of CAPs and shall advise the appropriate project and program manager if the plans are not implemented in a timely manner. In the case of significant conditions, the Lead QA specialist shall advise the appropriate TCEQ Management if CAPs are not implemented in a timely manner.
  • Depending upon program requirements, either the project manager or QA staff will notify affected management and the Lead QA specialist when corrective actions have been completed and verified to be effective, and that the associated CAP(s) can be closed. In the case of significant conditions, the Lead QA specialist shall advise the Project Manager and appropriate TCEQ Management when corrective actions have been completed and verified to be effective, and that the associated CAP(s) can be closed.
  • The current version of the TCEQ CAP template is available for download.