Part K — Performance & Improvement

Corrective action, management review and lessons learned

Workbook section 120 and 127

Owner

HSE Manager / Document Controller

Review / trigger

Annual review; update immediately if legal, authority, project, client, or scope requirements change.

Primary references

Plans TOC - Part K; K - Management Review Register; K - Lessons Learned Register; Plan K127 Management Review and; L - Corrective Action Register

Checkpoints

Open live checklist

#	Area	Checkpoint / Requirement	Evidence / Acceptance Criteria	Responsible	Frequency
1	Corrective Action Register	CAPA register accessible to all department heads via shared HSE management system	System access log showing department head accounts	HSE Manager	Ongoing
2	Corrective Action Register	Each CAPA includes a documented cost estimate for implementation of permanent fix	CAPA record with cost estimate field completed	HSE Officer	Per entry
3	Corrective Action Register	CAPA register reviewed at weekly HSE meeting with status update for each open item	Weekly HSE meeting minutes listing open CAPA statuses	HSE Manager	Weekly
4	Corrective Action Register	Corrective actions arising from client/consultant inspection reports logged within 24 hours of receipt	Register entry timestamp within 24 hours of report date	HSE Officer	Per report
5	Corrective Action Register	CAPA register includes a 'risk reduction achieved' field validated post-implementation	Register field showing before/after risk rating	HSE Manager	Per closure
6	Corrective Action Register	Corrective actions requiring design change routed through engineering change control process	Engineering change request form referencing CAPA ID	Project Engineer	As required
7	Corrective Action Register	CAPA register backed up and archived weekly to prevent data loss	Backup log showing weekly archive timestamp	IT/Document Controller	Weekly
8	Corrective Action Register	Corrective action ownership transferred formally and documented when responsible person leaves project	Handover memo naming new CAPA owner	HSE Manager	As required
9	Corrective Action Register	Open CAPA count and average closure time reported as KPI in monthly HSE report	Monthly HSE report showing CAPA KPI figures	HSE Manager	Monthly
10	Management Review Inputs	Review inputs include status of objectives and targets set at prior review	Objectives tracker attached to review pack showing progress	HSE Manager	Quarterly
11	Management Review Inputs	Review inputs include results of emergency preparedness drills and identified gaps	Drill evaluation summary included in review pack	HSE Manager	Quarterly
12	Management Review Inputs	Review inputs include feedback from client/consultant HSE performance evaluations	Client evaluation scorecard attached to review pack	Project Director	Quarterly
13	Management Review Inputs	Review inputs include contractor/subcontractor HSE performance ranking summary	Subcontractor ranking table in review pack	HSE Manager	Quarterly
14	Management Review Inputs	Review agenda circulated to attendees at least 5 working days before meeting	Calendar invite/email with agenda attached, dated 5 days prior	HSE Manager	Quarterly
15	Management Review Outputs	Review outputs assign a review date for reassessment of undecided action items	Minutes showing follow-up review date for pending items	HSE Manager	Quarterly
16	Management Review Outputs	Management review conclusions communicated to site workforce via toolbox talk or notice board	Toolbox talk record or notice board photo referencing review outcomes	Site Supervisor	Quarterly
17	Management Review Outputs	Review outputs evaluated against ISO 45001 certification maintenance requirements	Minutes cross-referenced to certification body requirements	HSE Manager	Quarterly
18	Management Review Outputs	Attendance register for management review meeting retained with signatures of all required roles	Signed attendance register on file	HSE Manager	Quarterly
19	Non-Conformance & Continual Improvement	Non-conformance register distinguishes between systemic and isolated occurrences	NC register with classification column populated	HSE Manager	Per entry
20	Non-Conformance & Continual Improvement	Improvement initiatives benchmarked against industry best practice or client corporate standard	Benchmarking report referenced in improvement plan	HSE Manager	Annually
21	Non-Conformance & Continual Improvement	Non-conformance findings communicated to relevant subcontractor within 48 hours of identification	Notification email/letter timestamped within 48 hours	HSE Officer	Per finding
22	Non-Conformance & Continual Improvement	Continual improvement plan approved by Project Director before implementation	Approved and signed improvement plan document	Project Director	Annually
23	Non-Conformance & Continual Improvement	Employee suggestion scheme for safety improvement reviewed and actioned monthly	Suggestion log with review decisions recorded	HSE Manager	Monthly
24	Non-Conformance & Continual Improvement	Non-conformance recurrence rate tracked as a formal KPI within the HSE dashboard	Dashboard showing recurrence rate metric	HSE Manager	Monthly
25	Lessons Learned	Lessons learned bulletins numbered sequentially and version-controlled	Bulletin log with sequential numbering system	HSE Manager	Ongoing
26	Lessons Learned	Lessons learned from other group projects/sites reviewed for applicability to current site	Cross-project lessons learned review record	HSE Manager	Quarterly
27	Lessons Learned	Lessons learned bulletins translated into languages spoken by majority workforce	Translated bulletin copies on file	HSE Officer	Per bulletin
28	Lessons Learned	Lessons learned effectiveness verified through subsequent audit or inspection observation	Audit note confirming lesson applied on site	HSE Manager	Per audit
29	Lessons Learned	New employee induction includes review of most significant recent lessons learned	Induction record referencing lessons-learned module	HSE Officer	Per induction
30	Audit Follow-Up	Audit finding closure verified through re-audit or site walk before status changed to closed	Re-audit/walk record confirming closure	HSE Manager	Per finding
31	Audit Follow-Up	Audit follow-up status reported to client/consultant where contractually required	Client status report referencing audit finding closures	HSE Manager	Per audit
32	Audit Follow-Up	Overdue audit findings included as standing item on weekly HSE meeting agenda	Weekly meeting minutes listing overdue audit findings	HSE Manager	Weekly
33	Audit Follow-Up	Audit finding trends analyzed to identify common weak areas across site departments	Trend analysis report by department/discipline	HSE Manager	Quarterly
34	Audit Follow-Up	Self-assessment audits scheduled ahead of external certification audits with gap closure plan	Self-assessment schedule and gap closure plan document	HSE Manager	Annually
35	Root Cause & Systemic Analysis	Root cause analysis method selected appropriate to incident severity (5-Why vs fault tree vs TapRooT)	RCA record indicating method used and justification	HSE Manager	Per incident
36	Root Cause & Systemic Analysis	Human factors (fatigue, workload, competency) considered explicitly within root cause analysis	RCA worksheet with human factors section completed	HSE Officer	Per incident
37	Root Cause & Systemic Analysis	Organizational/management system factors considered in addition to individual behavior in RCA	RCA worksheet showing organizational contributing factors	HSE Manager	Per incident
38	Root Cause & Systemic Analysis	RCA findings cross-checked against similar historical incidents for common causal patterns	Cross-reference note linking to prior incident IDs	HSE Manager	Per incident
39	Root Cause & Systemic Analysis	RCA team composition includes representation from operations, HSE and where relevant engineering	RCA meeting minutes listing attendee roles	HSE Manager	Per incident
40	Verification & Effectiveness Review	Verification of corrective action effectiveness scheduled and tracked with defined due date	Verification schedule with due dates per CAPA	HSE Manager	Per closure
41	Verification & Effectiveness Review	Verification includes worker feedback on whether the corrective action is practical and sustained	Worker feedback form/interview record attached to verification	HSE Officer	Per closure
42	Verification & Effectiveness Review	Ineffective corrective actions reopened and reassigned rather than closed with residual risk	Register entry showing reopened status with new due date	HSE Manager	As required
43	Verification & Effectiveness Review	Statistical sample of closed CAPAs re-verified quarterly by HSE Manager for quality assurance	Sample verification log with quarterly date	HSE Manager	Quarterly
44	Stakeholder Communication	Corrective action status shared with client/consultant at scheduled progress meetings	Progress meeting minutes referencing CAPA status update	Project Manager	Monthly
45	Stakeholder Communication	Workforce notified of corrective actions affecting their work area before implementation	Notification record/toolbox talk prior to implementation date	Site Supervisor	Per action
46	Stakeholder Communication	Corrective action communication includes rationale to support workforce buy-in and compliance	Communication material explaining rationale, filed with record	HSE Officer	Per action
47	Stakeholder Communication	Insurance/loss control provider notified of significant corrective actions where policy requires	Notification correspondence to insurer on file	HSE Manager	As required
48	Digital Systems & Data Integrity	CAPA and NC data entered into digital HSE system without unresolved duplicate entries	System duplicate-check report showing zero unresolved duplicates	HSE Manager	Monthly
49	Digital Systems & Data Integrity	Access rights to CAPA system restricted by role to prevent unauthorized status changes	User access rights matrix for CAPA system	IT/Document Controller	Quarterly
50	Digital Systems & Data Integrity	Audit trail of CAPA status changes retained within digital system for traceability	System audit trail export showing change history	HSE Manager	Ongoing
51	Digital Systems & Data Integrity	CAPA system generates automated reminder notifications to owners at 7, 3 and 1 day before due date	System notification log showing reminder timestamps	HSE Manager	Ongoing
52	Corrective Action Register	Central CAPA register maintained covering incidents, audits, inspections and near-misses	Register with unique CAPA ID, source, description, owner, due date, status	HSE Manager	Weekly
53	Corrective Action Register	Each corrective action assigned a single accountable owner by name, not by department	Register 'Owner' field populated with named individual	HSE Manager	Per entry
54	Corrective Action Register	Target closure dates set based on risk severity (immediate/24h/7d/30d tiers)	Register due-date column cross-checked against risk matrix tier	HSE Manager	Per entry
55	Corrective Action Register	Overdue corrective actions escalated to next management level after 2 reminders unaddressed	Escalation email/memo on file referencing overdue CAPA ID	HSE Manager	Weekly
56	Corrective Action Register	Root cause analysis (5-Why or fishbone) completed for all Category A/B incidents before CAPA raised	RCA worksheet attached to CAPA record	HSE Officer	Per incident
57	Corrective Action Register	Interim/temporary control implemented immediately pending permanent corrective action	Toolbox talk or work-order confirming interim control date	Site Supervisor	Immediate
58	Corrective Action Register	Corrective action verified as effective by an independent party before formal closure	Verification checklist signed by person not involved in original RCA	HSE Manager	Per closure
59	Corrective Action Register	Closed-out CAPA supported by photographic or documentary evidence of implementation	Photo/document attached to closed CAPA record	HSE Officer	Per closure
60	Corrective Action Register	Recurring corrective actions (same root cause twice in 12 months) flagged for systemic review	Trend flag in register with cross-reference to prior CAPA ID	HSE Manager	Monthly
61	Corrective Action Register	CAPA data reconciled with ADOSH-SF ADOSH-SF incident notification records for consistency	Reconciliation log matching ADOSH-SF reference numbers to CAPA IDs	HSE Manager	Monthly
62	Management Review Inputs	Management review agenda includes status of previous review action items	Prior meeting minutes attached with action tracker	HSE Manager	Quarterly
63	Management Review Inputs	Review inputs include incident/accident statistics, audit results and non-conformance trends per ISO 45001 Clause 9.3	Management review pack listing Clause 9.3 required inputs	HSE Manager	Quarterly
64	Management Review Inputs	Review inputs include results of participation and consultation with workers	Worker consultation minutes/survey summary in review pack	HSE Manager	Quarterly
65	Management Review Inputs	Review inputs include adequacy of resources for HSE management system	Resource adequacy statement signed by senior management	Project Director	Quarterly
66	Management Review Inputs	Review inputs include external/internal communications relevant to HSE, including regulator correspondence	Log of DM/ADOSH-SF correspondence reviewed in meeting	HSE Manager	Quarterly
67	Management Review Inputs	Review inputs include status of legal and other compliance obligations	Legal register with compliance status attached to review pack	HSE Manager	Quarterly
68	Management Review Outputs	Review outputs record opportunities for continual improvement per ISO 45001 Clause 10.3	Minutes listing improvement opportunities and owners	HSE Manager	Quarterly
69	Management Review Outputs	Review outputs record any need for changes to HSE policy or objectives	Minutes documenting policy/objective change decisions	Project Director	Quarterly
70	Management Review Outputs	Review outputs record resource allocation decisions with budget reference	Minutes with budget code/approval reference	Project Director	Quarterly
71	Management Review Outputs	Management review minutes signed off and circulated to relevant department heads within 5 working days	Distribution email/log with signed minutes attached	HSE Manager	Per meeting
72	Non-Conformance & Continual Improvement	Non-conformances classified by severity and linked to specific ISO 45001 clause or legal requirement breached	NC register with clause/legal reference column completed	HSE Manager	Per entry
73	Non-Conformance & Continual Improvement	Non-conformance corrective action addresses both immediate cause and underlying system failure	CAPA record shows both immediate fix and system-level action	HSE Officer	Per entry
74	Non-Conformance & Continual Improvement	Effectiveness of corrective actions reviewed at defined interval post-closure (e.g., 30/60/90 days)	Follow-up verification record dated per defined interval	HSE Manager	Per closure
75	Non-Conformance & Continual Improvement	Continual improvement plan updated annually reflecting audit, inspection and incident trend analysis	Signed and dated improvement plan document	HSE Manager	Annually
76	Non-Conformance & Continual Improvement	Preventive actions identified proactively from trend analysis, not only reactive to incidents	Trend analysis report with proactive action items listed	HSE Manager	Quarterly
77	Non-Conformance & Continual Improvement	Corrective action cost and resource impact tracked to support management review resourcing decisions	Cost/resource tracker linked to CAPA register	HSE Manager	Monthly
78	Lessons Learned	Lessons learned bulletin issued to all sites following any Category A (fatality/major) incident	Bulletin distribution record with acknowledgement receipts	HSE Manager	Per incident
79	Lessons Learned	Lessons learned repository maintained and accessible to project planning and design teams	Repository access log or shared-drive record	HSE Manager	Ongoing
80	Lessons Learned	Lessons learned incorporated into method statements and risk assessments for similar future work	Revised RAMS document referencing lessons-learned bulletin number	HSE Officer	Per new RAMS
81	Lessons Learned	Lessons learned reviewed and discussed during toolbox talks within 7 days of issue	Toolbox talk attendance sheet referencing bulletin topic	Site Supervisor	Per bulletin
82	Lessons Learned	Contract-wide lessons learned shared across all subcontractors on site via HSE committee	HSE committee minutes recording lessons-learned agenda item	HSE Manager	Monthly
83	Lessons Learned	Annual lessons-learned summary report compiled for inclusion in company HSE performance report	Annual report section listing key lessons and system changes made	HSE Manager	Annually
84	Audit Follow-Up	Internal audit findings tracked to closure with same rigor as incident-derived corrective actions	Audit findings register cross-referenced to CAPA register	HSE Manager	Per audit
85	Audit Follow-Up	External/third-party audit (e.g., ISO 45001 surveillance) findings assigned corrective action owners within 5 working days	Audit response plan dated within 5 days of report receipt	HSE Manager	Per audit
86	Audit Follow-Up	Major/critical audit non-conformances reported to top management immediately, not held for next scheduled review	Immediate notification email/memo to Project Director	HSE Manager	Per finding
87	Audit Follow-Up	Corrective action closure evidence retained for minimum 3 years for audit trail purposes	Document retention log confirming 3-year retention	HSE Manager	Ongoing

Each checkpoint records Status (Yes / No / N/A), Comments, Corrective Action and Sign-off. Switch to Complete in-app to fill it here, or download the blank version to complete on site.

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