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How to Resolve AASHTO re:source and CCRL Report Findings

By Jasmine Gilmore, Quality Analyst

Posted: August 2017

TItle-ResolveFindingsOne of the most frequently asked questions Assessors, Inspectors, and Quality Analysts receive is, “What do I need to do to resolve this finding?”.  While a laboratory may have effectively resolved a nonconformity internally, it is also important to understand what forms of evidence need to be submitted to the AASHTO Accreditation Program. In some cases, the laboratory’s proposed resolution does not address, or resolve the nonconformity, and further corrective action(s) will be required.

For a finding to be resolved, the laboratory must submit evidence that thoroughly addresses all aspects of the nonconformity/finding. The first step to resolving a nonconformity/finding is determining the root cause of the problem. See, Getting to the Root of the Problem: Root Cause Analysis (RCA) Explained for more information on this determination.

When responding to report findings, it can be easy to forget why the AASHTO Accreditation Program has such specific requirements.  We hold everyone to the standards and specifications for which their laboratory is maintaining or seeking accreditation.  Effectively resolving all findings and nonconformities prior to the deadline allows accreditation to be granted, or maintained, without the need and cost of an additional assessor visit to verify the corrective action has been implemented.    

There are four different types of findings that need to be addressed and resolved by a laboratory:

  • Procedural
  • Equipment
  • Quality Management
    • Policies and Procedures
    • Calibrations/Standardization/Check
    • Certification
  • Repeat

The following examples will provide you with guidance on how to best resolve the various types of nonconformities and provide you with more insight into why you may be asked for additional supporting information.

Procedural Findings

Nonconformity: A procedural finding indicates the physical demonstration of the test procedure was not performed in accordance to the test method.

How to resolve: These findings must be addressed and resolved by retraining the technicians on the step(s) that were incorrectly performed.  The laboratory must also submit evidence that indicates the retraining took place. Statements that indicate training will take place in the future will not be accepted.

Example Finding

T 11/C117 - The washing procedure was not performed by agitating the specimen in a container of water and decanting the wash water over the nest of sieves. The entire specimen was placed onto the sieve nest and washed.

Nonconformity Status Response(s)
accept
Resolved
Laboratory 1:The technician confused this test method with D1140 and performed this step incorrectly. The technician has been re-trained was observed demonstrating this test method properly.

paperclipPlease see the attached training record.

Nonconformity Status Response(s)
Cancel
Unresolved
Laboratory 2: We will re-train the technician.

Quality Analyst: What allowed this nonconformity to take place and   what is the laboratory now doing to prevent this from reoccurring? To resolve this nonconformity, the laboratory will need to submit evidence that indicates the technician has been retrained on this step. 

Why is this still marked as “Unresolved”? The laboratory’s response only indicates retraining will take place in the future.  The root cause of the issue has not been addressed and no evidence of the corrective action was submitted. 

Equipment Findings

Nonconformity: An equipment finding indicates a piece of equipment did not meet the specifications of a test method or malfunctioned during the on-site assessment/inspection.

How to resolve: There are two ways a laboratory can resolve an equipment finding:

  1. Replace- If the laboratory replaces the nonconforming equipment, it must attach a packing slip (invoices and order slips will not be accepted) or photo of the newly purchased and installed item.
  2. Repair- If the item was sent out for repair, the work order receipt must be submitted. If the item was repaired internally, the laboratory must clearly state how the item was repaired and submit necessary documentation that confirms the repair was completed (receipts, photos, videos, etc.).

In both cases, the laboratory must submit a calibration, standardization, or check record for the newly purchased or repaired item.

Keep in mind Statements of Traceability and Certificates of Compliance cannot be used in lieu of a calibration record.

Example Finding

D4318 - The point of contact on the base of the liquid limit device presented was worn to more than 10.0 mm (3/8 in.) in diameter. The diameter of the worn area was 11.29 mm.

Nonconformity Status Response(s)
accept
Resolved
Laboratory 1: We have purchased a new liquid limit device.

paperclipPlease see the attached standardization record and packing slip for the newly purchased liquid limit device.

Nonconformity Status Response(s)
Cancel
Unresolved
Laboratory 2: We have purchased a new liquid limit device.

paperclipPlease see the attached Certificate of Compliance that came with the liquid limit device.

Quality Analyst: Please submit a standardization record and photo or packing slip for the newly purchased liquid limit device.

Why is this still marked as “Unresolved”? It is not permissible to submit a Certificate of Compliance instead of a standardization or calibration record. In addition, the laboratory did not submit a photo or packing slip showing that it is now in possession of a newly acquired liquid limit device. 

Quality Management  - Policy or Procedure Findings

Nonconformity: A policy or procedure finding indicates that a specific documented policy or procedure was not presented, or did not conform to the applicable Quality Management System standard (R 18, C1077, D3740, E329, etc.).

How to resolve: The laboratory must submit the documented policy or procedure noted in the finding that conforms to the applicable Quality Management System standard. The AASHTO Accreditation Program will not accept a proposed statement that will be added to the quality manual.  The laboratory must attach a copy or screenshot of the policy or procedure.

Example Finding

R 18 - A procedure for producing test reports was not presented.

Nonconformity Status Response(s)
accept
Resolved
Laboratory 1:We have added a procedure for producing test reports to our quality manual.

paperclipPlease see the attached procedure.

Nonconformity Status Response(s)
Cancel
Unresolved
Laboratory 2:The following statement has been added to the quality manual, “Test reports shall be produced in accordance to R 18”

Quality Analyst: Please submit a copy or screenshot of the actual procedure that documents how the laboratory produces test reports.

Why is this still marked as “Unresolved”? The laboratory did not submit a copy or screenshot of the procedure for producing test reports. In addition, the submitted statement is not an actual procedure, so even if this statement was attached in a separate document, it does resolve this finding.

Quality Management - Calibration/Standardization/Check Findings

Nonconformity: This type of finding indicates a calibration, standardization, or check record was not presented, or did not conform to an applicable Quality Management System standard, test method, or test specification.

How to resolve: The laboratory must submit a calibration, standardization, or check record for the item noted in the finding that conforms to the applicable test method or test specification and applicable Quality Management System standard(s).

Keep in mind Statements of Traceability and Certificates of Compliance cannot be used in lieu of a calibration record.

Common Issues: There are a few reasons why you may be going back a forth with your Quality Analyst over this type of finding. The most common reason for this occurrence is the laboratory’s unfamiliarity of the individual requirements of the test standard or specification and the applicable Quality Management System standards.

While the report may have indicated missing or nonconforming calibration, standardization, or check records, the submitted documents to the Quality Analysts must still conform to the test method or test specification in addition to the requirements of any applicable Quality Management System standards even if each of these requirements are not explicitly written in the nonconformity/finding.

Example Finding

R 18 - Sieving sufficiency records were not presented.

Nonconformity Status Response(s)
accept
Resolved
Laboratory 1: paperclipI have attached current sieving sufficiency records

Quality Analyst: Thanks for the submitted records. Unfortunately, the records are missing the initial mass, pan mass, and final mass (per T 27/C136). In addition, the records are also missing reference to the in-house calibration procedure (per R 18). 

Laboratory 1: paperclipThank you for the feedback.  Please see the attached corrected records.

Nonconformity Status Response(s)
Cancel
Unresolved
Laboratory 2: paperclip I have attached current sieving sufficiency records.

Quality Analyst: Thanks for the submitted records. Unfortunately, the records are missing the initial mass, pan mass, and final mass (per T 27/C136). In addition, the records are also missing reference to the in-house calibration procedure (per R 18). 

Laboratory 2: The finding does not make any mention of those items being missing. I have submitted this same format for the last 10 assessments and it has been accepted.  Please see my first attachment.

Why is this still marked as “Unresolved”? The laboratory has not submitted sieving sufficiency records that conform to both test methods (T 27/C136) and the Quality Management System standard (R 18). Even though the individual requirements of the records are not written in the finding, the laboratory is still responsible for ensuring the records conform to all applicable standards.

Quality Management- Certification Findings

Nonconformity: This type of finding indicates the laboratory has not submitted evidence of conformance to the personnel certification requirements specified in the applicable ASTM Quality Management System standard(s).

How to resolve: The laboratory must submit copies of the certifications, transcripts, and/or appropriate documentation that demonstrate conformance to the personnel qualification and certification requirements as specified in the applicable ASTM Quality Management System standard(s). It is not permissible to revise an organization chart to avoid getting a technician certified.

See the AASHTO Accreditation Policy on Certifications for more information on certification requirements.

Example Finding

ASTM D3666 - Documents were not presented to show that the Testing Technician Supervisor, John Doe, meets the certification requirements of D3666 (Asphalt Mixture).

Nonconformity Status Response(s)
accept
Resolved
Laboratory 1: John Doe has since obtained the Asphalt Mixture III Certification.

paperclipPlease see the attached certification.

Nonconformity Status Response(s)
Cancel
Unresolved
Laboratory 2: We have revised our organization chart and John Doe is no longer a supervisor and does not need to be certified.

Quality Analyst: Based on the assessor’s documentation and the organization chart submitted during the most recent Annual Review, it appears that John Doe oversees Asphalt Mixture testing. Please submit a plan of action that details how, and when, John Doe will obtain an Asphalt Mixture certification. We will follow-up on this issue in a future Accreditation Event.

Why is this still marked as “Unresolved”? Instead of obtaining the proper certification, the laboratory revised the organization chart in attempts to avoid needing certification.  

Repeat Findings

Nonconformity: A repeat finding indicates a similar finding was noted during a previous assessment/inspection.

How to resolve: These findings must be addressed and resolved by submitting an Assessment Corrective Action Report that details the root cause analysis and plan to monitor the effectiveness of the corrective action.

Example Finding

T11/C117- The washing procedure was not performed by agitating the specimen in a container of water and decanting the wash water over the nest of sieves. The entire specimen was placed onto the sieve nest and washed. A similar finding was noted during the previous assessment, Report R12345. This indicates that the previous action taken to resolve the issue may not have been effective.

Nonconformity Status Response(s)
accept
Resolved
Laboratory 1: The technician confused this test method with D1140 and performed this step incorrectly. The technician has been re-trained and was observed demonstrating this test method properly. A different technician performed this demonstration.

paperclipPlease see the attached training record and corrective action report that addresses this repeat finding.

Nonconformity Status Response(s)
Cancel
Unresolved
Laboratory 2: We will re-train the technician

Quality Analyst: To resolve this finding, we will need to see submitted evidence that indicates the technician has already been retrained on this step. In addition, because this is a repeat finding, please submit a corrective action report.

Why is this still marked as “Unresolved”? The laboratory’s response does not indicate this finding has been presently addressed. In addition, an Assessment Corrective Action Report was not completed or attached.

      

It is important to know that when resolving your nonconformities, the goal isn’t to please the Quality Analyst, but to ensure and continue standard conformance within your laboratory. Take your time and determine the root cause of the problem and submit sufficient evidence that shows the nonconformity has been addressed and corrected. You do not want to rush through your responses for the sake of closing out your Accreditation Event, as you will find that this is counterproductive and will only require the laboratory to do additional work. To avoid unnecessary back and forth with your Quality Analyst, take your time with your responses and ensure you have submitted the required evidence to address the nonconformity prior to the deadline. If you have any questions about the feedback you have received from your Quality Analyst, or are still unsure of what to submit to resolve a nonconformity, feel free to call or e-mail the Quality Analyst that is assigned to your on-site assessment review.

 

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