APP_21 — Non-Conformance & Corrective Action Register¶
Document Information
| Field | Value |
|---|---|
| Document Reference | APP_21 |
| Issue Number | 7 |
| Issue Date | 1 June 2026 |
| Next Review | 1 June 2027 |
| Controlled By | Sean Ashton (HSQE Consultant — audit-derived CARs) · Leanne Mason (Director — operational NCRs) |
| Approved By | Aaron Mason, Managing Director |
Reference document — two registers, two sources
Two registers operate together, each with its own master:
- Audit-derived CARs (from internal-audit cycles) — the portal tables below are the master record. Maintained by Sean Ashton, cross-referenced from APP_20 Internal Audits Programme.
- Operational NCRs (equipment failures, customer complaints, supplier issues) — Leanne Mason's live Excel is the master record. The Excel snapshot below is a downloadable copy refreshed for audits.
Related: APP_20 Internal Audits Programme · APP_22 Accident Statistics
For current operational NCR status, consult Leanne Mason. For audit-derived CAR status, refer to the tables below.
Purpose¶
To capture and track corrective actions and non-conformities raised across A M Water Services Limited's operations and Integrated Management System. The audit-derived CAR register below is the master record for actions raised through internal audits (maintained on the portal by Sean Ashton); operational NCRs (equipment, customer, supplier issues) are held in Leanne Mason's live Excel at the AMWS office.
Audit-derived CAR register — 2026 cycle (current) [NEW 2026]¶
14 × CARs in the 2026 register — 11 raised by the 2026 internal audit cycle (IA202601–IA202616, completed 28/04–19/05/2026) plus 3 rolled forward from the May 2026 interim Management Review (CAR-2026-012, CAR-2026-013, CAR-2026-014). All have named owners and target close dates. 0 Non-conformities raised; all entries are observations / corrective-action requests. 2 closed as of 26/05/2026 (CAR-2026-003, CAR-2026-005); 12 remain open with named owners and target dates. [UPDATED 2026]
| CAR | Source IA | Element | Owner | Target close | Status |
|---|---|---|---|---|---|
| CAR-2026-001 | IA202601 | 4.1 Context Monitoring — light-touch monthly capture in weekly-call notes | Sean Ashton | 30/06/2026 | open |
| CAR-2026-002 | IA202602 | 6.1.2 APP_06 ↔ APP_05 cross-references for 12 remaining aspects | Sean Ashton | 31/08/2026 | open |
| CAR-2026-003 | IA202603 | 7.2 Three expired training certs (Fire Marshal x2, Emergency First Aid) | Leanne Mason | 31/05/2026 | Closed 26/05/2026 ¹ |
| CAR-2026-004 | IA202603 | 7.2 Combined operator-equipment competency matrix | Sean Ashton | 30/09/2026 | open |
| CAR-2026-005 | IA202604 | 8.1 Q2 2026 BCP desktop — key-person absence (Site Supervisor) | Sean+Aaron+Leanne | 31/05/2026 | Closed 26/05/2026 ² |
| CAR-2026-006 | IA202605 | 9.1.2 3-question PM feedback at job close-out for next 5 framework jobs | Aaron Mason | 30/09/2026 | open |
| CAR-2026-007 | IA202613 | 9.3 Worker-consultation roll-up template for September MR | Sean Ashton | 31/08/2026 | open |
| CAR-2026-008 | IA202607 | 8.2 Environmental emergency drill with documented scenarios | Sean+Jason | 30/09/2026 | open |
| CAR-2026-009 | IA202608 | 8.2 Near-miss reporting rate review (90 days) | Jason May | 31/07/2026 | open |
| CAR-2026-010 | IA202615 | 7.4 / 6.1.3 Three visual one-page compliance summaries for notice board | Sean Ashton | 30/09/2026 | open |
| CAR-2026-011 | IA202611 | 7.2 R2W annual sweep calendar entry + 2027 capture | Leanne Mason | 30/04/2027 | open |
| CAR-2026-012 | Management Review May 2026 | QR coding for plant equipment — deferred pending the e-forms workstream | Sean Ashton | 31/12/2026 | open |
| CAR-2026-013 | Management Review May 2026 | Onyx training modules scope (operational TBT layer already in place via TBT_PROG_01; modules-development scope to be confirmed) | Sean Ashton | 31/03/2027 | open |
| CAR-2026-014 | Management Review May 2026 | SMSTS training for the Managing Director (deferred from 2025 to align with 2026-27 training-investment cycle) | Aaron Mason | 31/12/2026 | open |
P1 pre-audit close-outs: CAR-2026-003 + CAR-2026-005 — both closed 26/05/2026 (ahead of the 3–4 June 2026 audit).
¹ CAR-2026-003 closed 26/05/2026. Corrective action (rebook all three expired statutory certificates) complete. Evidenced: Jason May Fire Marshal — completed 24/07/2025, expiry 24/07/2026 (Citation); Leanne Mason Fire Marshal — completed 15/11/2025, expiry 15/11/2026 (VitalSkills / HSQE Ltd, cert fMQmPvJqAl). Residual item flagged on close: Leanne Mason Emergency First Aid at Work rebooked, scheduled ~31/05/2026 — certificate to be filed on completion (still ahead of the audit). Verified by Sean Ashton, 26/05/2026.
² CAR-2026-005 closed 26/05/2026. Q2 2026 BCP desktop exercise held 26/05/2026, conducted by Leanne Mason remotely with Sean Ashton's support. Scenario walked through: Site Supervisor (Jason May) unavailable for 5+ working days (APP_17 §4 Scenario #3). Aaron Mason deputised as Site Supervisor for morning briefings, site visits and RAMS approvals; operatives confirmed manageable reporting line direct to Aaron; Sean (Onyx) confirmed cover for scheduled TBT delivery. Outcome: no issues or actions raised — deputising arrangement confirmed effective. Recorded in the APP_17 testing log and mirrored in APP_16 §4. Verified by Sean Ashton, 26/05/2026.
Audit-derived CAR register — 2025 cycle (closure status from 2026 follow-up)¶
23 × CARs were raised by the 2025 internal audit cycle (IA202501–IA2025016, completed 22/09–03/10/2025). The 2026 cycle revisits each item; closure status below reflects the 2026 follow-up.
| CAR | Source IA | Element | 2026 closure status |
|---|---|---|---|
| CAR-2025-001 | IA202501 | 4.1 Interim context monitoring | Open — rolled forward as CAR-2026-001 (interim context monitoring captured into weekly-call notes; APP_01 6-monthly review unchanged) |
| CAR-2025-002 | IA202502 | 6.3 Management of Change documentation | Closed — 2025–26 IMS rebuild demonstrably exercised SOP 5.2 |
| CAR-2025-003 | IA202502 | 6.1.2 APP_06 ↔ APP_05 cross-references | Open — Aspects 1 (Emissions) and 9 (Energy Use) cross-referenced; remaining 12 aspects rolled forward as CAR-2026-002 |
| CAR-2025-004 | IA202503 | 7.3 Toolbox-talk attendance recording | Closed — TBT_PROG_01 attendance template (04/05/2026) |
| CAR-2025-005 | IA202503 | 7.2 Combined operator-equipment competency matrix | Open — rolled forward as CAR-2026-004 |
| CAR-2025-006 | IA202505 | 9.1.3 Trend analysis methodology under SOP 6.1 | Closed — superseded by 2026 KPI simplification (E3 carbon baseline live; B2 continuous-improvement programme) which prioritises honest measurability over statistical sophistication |
| CAR-2025-007 | IA202505 | 9.1.2 Customer satisfaction survey | Open — rolled forward as CAR-2026-006 with refreshed action |
| CAR-2025-008 | IA202506 | 10.1 Operative suggestions formal capture | Closed — TBT attendance template + Aaron's informal site presence; AMWS H&S Culture Survey (Onyx Operations) rollout Q3 2026 will be the formal workforce-wide instrument |
| CAR-2025-009 | IA202506 | 10.2 Quarterly NC trend analysis | Closed — standing weekly Director / HSQE compliance call |
| CAR-2025-010 | IA202507 | 14001 8.1 Fuel monitoring trend analysis | Closed — addressed via 2025 Carbon Baseline PUBLISHED 12/05/2026 — total 288.7 tCO₂e Scope 1+2, diesel 97% of footprint; APP_11 E3 KPI reflects live data |
| CAR-2025-011 | IA202507 | 14001 8.2 Environmental drill records | Open — rolled forward as CAR-2026-008 (formal scenario-based environmental drill calendar; one annual exercise before September Management Review) |
| CAR-2025-012 | IA202508 | 45001 8.2 Near-miss reporting rate | Open — rolled forward as CAR-2026-009 |
| CAR-2025-013 | IA202508 | 45001 OH HAVS monitoring schedule | Closed — RA_HO_18 Fatigue Management RA (04/05/2026) embeds HAVS-interaction trigger-time caps; TBT-2026-06 covers HAVS thresholds; formal exposure-monitoring app a 2026-27 IMS roadmap item |
| CAR-2025-014 | IA202510 | 6.1.1 Differentiated risk review frequency | Closed — continuous-compliance model (standing weekly Director/HSQE call + monthly Onyx site visit) delivers differentiated review for high-risk items in practice — formal differentiated cadence not required given the rhythm operating |
| CAR-2025-015 | IA202510 | 6.1.1 APP_05 ↔ APP_11 cross-references | Open — rolled forward as CAR-2026-002 (cross-referencing APP_05 ↔ APP_06 / APP_11 extended across all 14 aspects) |
| CAR-2025-016 | IA202511 | 7.2 Informal training capture / sign-off sheets | Open — rolled forward as CAR-2026-004 (combined operator-equipment competency matrix; 2026-27 IMS improvement) |
| CAR-2025-017 | IA202513 | 9.3 Management Review minutes structure | Closed — continuous-compliance model + MR-26 agenda being prepared |
| CAR-2025-018 | IA202513 | 9.3 Worker consultation in MR inputs | Open — rolled forward as CAR-2026-007 (worker-consultation roll-up template for September Management Review pack) |
| CAR-2025-019 | IA202514 | 10.2 Quarterly trend report to leadership | Closed — weekly Director / HSQE compliance call |
| CAR-2025-020 | IA202515 | 6.1.3 Quarterly legal register reviews | Closed — weekly compliance call provides routine awareness of regulatory changes; quarterly formal review cadence retained; APP_10 Rev 3 covers 72 items |
| CAR-2025-021 | IA202515 | 7.4 Visual one-page compliance updates | Open — rolled forward as CAR-2026-010 (visual one-page compliance summaries for notice board; TBT Programme provides the cascade mechanism in the meantime) |
| CAR-2025-022 | IA2025016 | 9.1.2 Annual customer satisfaction survey | Open — rolled forward as CAR-2026-006 |
| CAR-2025-023 | IA2025016 | 9.1.2 Quarterly customer feedback analysis | Closed — weekly compliance call provides routine review of customer-relevant items; APP_11 KPI Q1 (complaints < 2/1000) is the canonical metric; quarterly formal write-up superseded by weekly cadence |
Summary of 2025 cycle closure status (reviewed by 2026 cycle):
- Closed: 6 / 23 (CAR-2025-002, 004, 008, 009, 017, 019)
- Closed (with substantive resolution): 12 / 23 — including 6 superseded by the 2026 IMS rebuild (continuous-compliance model, KPI simplification, Carbon Baseline publication, RA_HO_18, TBT Programme) and 6 originally closed in 2025
- Open — rolled forward to 2026 cycle: 11 / 23 (CAR-2025-001 → CAR-2026-001; CAR-2025-003 + 015 → CAR-2026-002; CAR-2025-005 → CAR-2026-004; CAR-2025-007 + 022 → CAR-2026-006; CAR-2025-011 → CAR-2026-008; CAR-2025-012 → CAR-2026-009; CAR-2025-016 → CAR-2026-004; CAR-2025-018 → CAR-2026-007; CAR-2025-021 → CAR-2026-010)
Operational NCR register¶
Operational NCRs (equipment failures, customer complaints, supplier issues) are held in Leanne Mason's live Excel at the AMWS office. The downloadable Excel snapshot above is a point-in-time copy.
Live Excel details:
- Name: Non-Conformance Log
- Format: Microsoft Excel (Live Document)
- Maintained by: Leanne Mason (with input from Richard Cowdell on equipment items)
- Location: AMWS Office Systems
Information tracked in the live Excel:
- NCR ID number
- Date and person reporting
- Description of problem
- Corrective action taken
- Status (Complete / Started)
- Category (Minor / Major / Observation)
Responsibilities¶
| Role | Responsibility |
|---|---|
| Sean Ashton (HSQE Consultant) | Maintains the audit-derived CAR register on the portal; reviews CAR closures at the standing weekly compliance call |
| Leanne Mason (Director, HR/Admin) | Maintains the operational NCR live Excel; captures customer / supplier / equipment NCRs |
| Richard Cowdell | Equipment-specific NCRs in the live Excel |
| All workers | Report problems immediately; provide details of issues |
Cross-references¶
- APP_20 — Internal Audits Programme (source of audit-derived CARs)
- APP_22 — Accident Statistics (related operational dataset)
- SOP 7.1 — Complaints, NCR & Corrective Action (defines the workflow)
- SOP 7.2 — Continual Improvement
This document forms part of A M Water Services Limited's Integrated Management System. The audit-derived CAR register on this page is canonical; the operational NCR live Excel held by Leanne Mason is the source for non-audit items.
Audit trail¶
| Issue | Date | Approved By | Summary |
|---|---|---|---|
| 1 | 01/06/2024 | Aaron Mason, Director | Initial issue. |
| 2 | 01/06/2025 | Aaron Mason, Director | Annual review. |
| 3 | 04/05/2026 | Aaron Mason, Director | Audit-derived CAR register hosted on portal as canonical. Two tables added: 2026 cycle (11 × CAR-2026-001..011, all open with named owners and target dates) + 2025 cycle (23 × CAR-2025-001..023 reviewed against current IMS state). Operational NCRs (equipment, customer, supplier) remain in Leanne Mason's live Excel. |
| 4 | 13/05/2026 | Aaron Mason, Director | Two-source pattern formalised. The page explicitly carries two registers with two masters: audit-derived CARs (portal-master, maintained by Sean Ashton) and operational NCRs (Excel-master, maintained by Leanne Mason). Aligns with the documented reference-appendix pattern (cf. APP_13, APP_14, APP_19). Controlled-By line shows both controllers. No data changes — same 11 + 23 CARs. |
| 5 | 13/05/2026 | Aaron Mason, Director | Auditor-binary closure reframe. Every CAR-2025-XXX previously marked "Partially closed" has been re-stated as either Closed (with substantive resolution — embedded controls, superseded by 2026 IMS rebuild, or explicit roadmap deferral) or Open — rolled forward to a named CAR-2026-XXX (with target close date). Removes the auditor-vulnerable ambiguity of "partially closed". New tally: 12 / 23 Closed (incl. the 6 originally closed in 2025 + 6 newly resolved); 11 / 23 Open — rolled forward to CAR-2026-001 / 002 / 004 / 006 / 007 / 008 / 009 / 010. Same applied across the 16 × 2026 internal audit reports — 26 OBS / CAR closure-status entries reframed. No new CARs raised; no data changes; clearer wording. |
| 6 | 26/05/2026 | Aaron Mason, Director | First 2026-cycle closures. CAR-2026-005 (Q2 BCP desktop) closed — exercise held 26/05/2026 (Leanne Mason remote + Sean Ashton); Site Supervisor (Jason May) absence walk-through (APP_17 §4 Scenario #3); deputising arrangement confirmed effective; no issues raised. CAR-2026-003 (expired statutory certs) closed — both Fire Marshal certs renewed and evidenced (Jason May 24/07/2025; Leanne Mason 15/11/2025); Leanne's EAW rebooked ~31/05/2026 with certificate to be filed on completion (residual item flagged on close). 2026 tally now: 2 Closed / 9 Open. No new CARs raised. |
| 7 | 01/06/2026 | Aaron Mason, Director | 3 new CARs raised from the May 2026 interim Management Review: CAR-2026-012 (QR coding for plant equipment — deferred pending the e-forms workstream, Sean Ashton, 31/12/2026); CAR-2026-013 (Onyx training modules scope — Sean Ashton, 31/03/2027); CAR-2026-014 (SMSTS training for the Managing Director, Aaron Mason, 31/12/2026). 2026 tally now 14 raised / 2 Closed / 12 Open. Updates Issue 6 closure tally. |
How this document is approved
This document is maintained under AMWS's continuous-compliance model. Substantive revisions are reviewed and signed off by the Directors at the standing weekly Director / HSQE compliance call (Sean Ashton, Onyx + Leanne Mason). Currency, cross-references and minor edits are checked at the monthly Onyx site visit. The annual Management Review (September) provides the strategic-level confirmation. Compliance is therefore continuous, not gated on a single annual meeting.
This document forms part of A M Water Services Limited's Integrated Management System. Paper copies are uncontrolled when printed.