Pipeline Construction: Quality Issues and Solutions Action Plans
Pipeline Construction: Quality Issues and Solutions Action Plans
Pipeline Construction:
Quality Issues and Solutions Action Plans
Table of Contents
Team Members............................................................................................................................................ ii
Background ................................................................................................................................................. 1
Conclusion ................................................................................................................................................. 12
Appendix A – Example Applications of the QMS Elements for Pipeline Construction Projects
pertaining to Pipe Coating and Welding................................................................................................. 13
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices i
Team Members
1
Working Group Lead
2
Technical Leads
3
Drafting Team
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices ii
Background
Early in 2007, the United States experienced a significant increase in pipeline construction activities,
including construction of “80% special permit” pipelines. During PHMSA’s inspections of these
projects, quality issues, such as, issues with pipeline coating, welding and backfilling were
experienced. By late 2007, PHMSA and industry began discussing these quality issues and
recognizing the need for improvement.
In March 2009, the INGAA Foundation responded to these discussions by hosting a two day
workshop focused on the “areas of concern” seen during different construction phases. In April
2009, PHMSA also hosted a workshop in collaboration with its State partners, the Federal Energy
Regulatory Commission (FERC) and Canada’s National Energy Board (NEB) aimed at informing the
public, alerting the industry, reviewing the lessons learned from these inspections, and improving
new pipeline construction practices prior to the 2009 construction season.
From the two meetings, INGAA held a Pipeline Summit to identify working groups to address
specific issues. The format was designed to communicate experiences and progress from
construction contractors, pipeline companies, INGAA Foundation member companies and others.
PHMSA also made presentations to the group assembled. INGAA developed an action plan to
address specific issues with workgroups.
An INGAA Foundation workgroup was created to review quality management system (QMS)
concepts and how they might be applied to pipeline construction projects. This white paper is the
result of this collaborative effort.
The objective of this white paper is to provide an overview of quality management system principles
and outline the benefits of applying these principles to the field implementation phase of pipeline
construction projects.
Since quality management systems (QMS) are central to the management of pipeline system assets
throughout their lifecycle, INGAA has included QMS for construction projects as a focus area within
the IMCI initiative. In 2011, drawing on the experience of the team that has developed this
document, INGAA formed a second team to examine how management systems can be applied more
broadly in verifying pipeline integrity.
The IMCI team working on management systems began its work by providing guidelines on
improving safety culture, and improving management of change practices. The team began with
safety culture as INGAA members have embraced a goal of zero incidents within their personnel
safety programs and within their pipeline integrity management programs. Understanding how
operators have designed their personnel safety programs to achieve the goal of zero was the place to
begin as safety culture is a key aspect of a broad-based management system.
The team is currently developing an overview of management systems in industries where the
consequences of failure can be unacceptable, including the chemical manufacturing, petroleum
refining, nuclear power, aviation, as well as the medical field. In many instances, the regulators in
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 1
these industries have elected to use management systems to audit and evaluate the effectiveness of
safety, as well as environmental programs. Standards being reviewed include those of the Federal
Aviation Administration (FAA), Occupational Safety and Health Administration, the Environmental
Protection Agency and the as well as international standards.
Implementing a QMS on pipeline construction projects improves material and construction quality
by providing a structured approach to quality management. INGAA intends to clarify and improve
its application of QMS. Through effective QMS, pipeline construction project sponsors can achieve
consistent conformance to established quality standards and specifications, reducing rework and
unexpected construction issues. Project sponsors, suppliers, contractors and service providers, all
need to work together to embrace higher standards of quality through the application of QMS
principles.
Achieving a consistent and uniform level of quality management across the pipeline construction
industry is a challenge well suited for the INGAA Foundation, Inc. (Foundation), which represents
pipeline operators, suppliers, contractors and service providers. INGAA formed the Foundation in
1990 to advance the use of natural gas and to facilitate the efficient construction and safe, reliable
operation of the North American natural gas pipeline system. The Foundation has proven to be an
effective forum to tackle construction issues because all key industry sectors are represented. The
Foundation has sponsored and will continue to sponsor workshops aimed at achieving a consistent
and uniform level of quality management across the pipeline construction industry.
In addition to this white paper, the INGAA Foundation published guidelines on Personal Protective
Equipment (PPE), Standards for Procurement and Installation of Field Segmentable Bends and Field
Applied Coatings Best Practices. These documents, along with other industry wide guidelines, are
posted on the www.ingaa.org website. Also, the INGAA Foundation will publish other white papers
and guidelines in 2012. Improved construction practices will include:
1. Overhead lines;
2. Excavations, and
3. Hydrostatic Testing will be published in 2012. Other Guidelines will follow.
The INGAA Foundation is presently evaluating study proposals that will continue to build on the
work and white papers described above in the area of Construction QMS. This future work will be
aligned and linked to the strategy and efforts of the IMCI work team at INGAA.
Quality systems have evolved over time. Until the early 19th Century, individual craftsmen ensured
the quality of their goods and services. With the Industrial Revolution, which transformed
manufacturing from using individual craftsmen to groups of laborers performing specialized tasks, it
was found that since no one person was responsible for the complete product, the methodology of
assuring quality had to change. Quality was principally managed by inspection from that point on,
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 2
and defective products were either scrapped or reworked. This was the introduction of the Quality
Control era.
During World War II, the military relied on civilian manufacturing to produce munitions and military
equipment. Quality issues and safety concerns required the inspection of every piece. This method of
Quality Control required military scale inspection resources that were simply not sustainable after the
conflict ended. A new quality methodology was developed which utilized statistical data to improve
processes throughout the manufacturing cycle. Now only a portion of the products being produced
would have to be inspected, since the production processes were stable, and produced few defects.
This was the era of statistical quality control.
By the 1980’s, most manufacturers had embraced a total quality management (TQM) system, which
focused on not only statistics, but quality approaches that encompassed the entire organization. The
Europeans had developed the ISO 9000 series of quality management standards, introducing the idea
that confidence in a product or service could be gained through the use of an approved quality
management system. Since the 1990’s, the ISO 9001 quality management standard has proven itself
to be the most used and most effective basis for building an effective and efficient system to control
the quality of a wide range of products and services. It is universally accepted.
Over time, industry sectors recognized the need to develop more industry specific standards to reduce
risks, meet industry specific needs and maintain compliance with statutory and regulatory
requirements. In 2002, American Petroleum Institute (API) and ISO worked together to develop
ISO/TS (Technical Specification) 29001, Petroleum petrochemical and natural gas industries –
Sector-specific quality management systems – Requirements for product and services supply
organizations. API published its 7th edition of API Specification Q1, Specifications for Quality
Programs for the Petroleum, Petrochemical and Natural Gas Industry on June 15, 2003 and the
jointly developed ISO/TS 29001 was published three months later. The documents are identical,
except for an annex in Q1 relating to API administration. On December 1, 2007, the second edition
of ISO/TS 29001 was published and subsequently back-adopted by API as the eighth edition of API
Spec Q1.
API Spec Q2, Specification for QMS Requirements for Service Supply Organizations for the
Petroleum and Natural Gas Industries, was published by API in late 2011. Spec Q2 seeks to address
service-specific quality concerns in the upstream petroleum industries. With the release of API Spec
Q2, API Spec Q1 is now under revision (future ninth edition) to remove the references to the
provision of services and focus the scope of the document on manufacturing activities only. While
not directly applicable to the construction of pipeline systems, contractors who provide services to
the pipeline construction industry may find Q2 to be a valuable reference.
Companies have always written specifications for their projects, provided those specifications to the
Contractors, and the Contractors have been building these projects in accordance with the
specifications. Companies have traditionally provided inspection services, and are responsible to
assess them to ensure the work was done correctly and to specification.
Companies approach both pipeline construction and quality in different ways and have relied on
regulations, standards, specifications, company construction personnel, and third-party inspection
contractors to address quality within pipeline construction. However, these typically require only
quality control measures and there are not generalized requirements for quality assurance or for a
complete Quality Management System (QMS).
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 3
Benefits of Using Modern Quality Practices
A QMS does not guarantee a flawless product or service without defect, but provides a framework for
maximizing the delivery of a product or service. Three major benefits of implementing an effective
QMS are:
Increased Efficiency
Developing a QMS requires some thought on the scale / nature of the project, the associated
processes, and how to maximize quality and efficiency. A fully implemented QMS provides the
processes and guidelines to follow, making training, transitions, and trouble-shooting easier.
Better Planning - resulting in fewer emergencies and surprises, less stress, less “firefighting”,
reduced costs from reductions in waste and effort, and increased effectiveness of training;
Continual Improvement - providing a Corporate Memory which avoids repeating issues/re-work
that carries lessons learned to future projects;
Improved Employee Morale- through defined roles and responsibilities, accountability of
management, established training systems and a clear picture of how their roles affect quality and
the overall success of the company;
Stronger Supplier Relationships - requiring thorough evaluation of suppliers (new and
existing)and subcontractors before a change is made and/or consistency with respect to how and
where orders are placed; and
Improved Control over Documentation - requiring documentation of all processes (and changes
therein), errors and discrepancies, ensuring consistency throughout production, accountability of
all personnel, and traceability through records.
A QMS developed for pipeline construction incorporates the same principles of a QMS for any other
industry. All processes from front end design, procurement, route selection and pipeline construction
are defined, outlined and documented, minimizing room for error. Even the process of making
changes to a process is documented, ensuring that changes are well planned and implemented in the
best possible way to maximize efficiency. Therefore, the benefits of a QMS for pipeline construction
is similar to those listed above.
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 4
Regulatory compliance is a benefit of implementing a QMS for a pipeline construction project, but
this is not the underlying goal. An effective QMS will provide far more benefit than just regulatory
compliance. The purpose of quality management is to promote conformance and discourage repeat
non-conformances relative to performance requirements established by a project.
Thinking of a construction project as a collection of processes is central to the success of the QMS; a
benefit being the QMS provides effective organization of the processes required to produce a
conforming construction project, using a capable and efficient approach. The QMS is essentially a
management tool that organizes work practices, which over time will lead to continual improvements
in pipeline and station construction.
Cost avoidance is a potential residual benefit of a structured QMS for a pipeline construction project,
because the primary focus of the QMS is to minimize failures/rework, improve conformance to
company and industry specifications and to maintain compliance with regulations.
The following diagram illustrates the concept of a pipeline project with ineffective quality
management processes. Each plate represents a process within the QMS and the holes represent
deficiencies within each of the processes. Individually, each process may be “adequately” defined
for the task at hand. On a case-by-case basis, each deficiency in the process may be relatively
insignificant and appear to pose no immediate threat to the project’s success. However, as in this
example, the aligning holes represent deficiencies that lead to overall project failure. Therefore, as
seen in this example, a pipeline construction project can successfully meet its goals and objectives if
it can eliminate deficiencies by better establishing the key processes of the QMS. The poorly defined
processes in this example resulted in failure, due to defective pipe ending up on the right-of-way.
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 5
When Quality Does Not Happen
Results:
Final Inspection
Unscheduled Downtime Receiving Inspection
Transportation Procedures
Delays
QC Personnel Training & Competency
Increased Costs Purchasing Procedures
Damaged Equipment
Failure QA
Injuries
Process Deficiencies
Quality System)
Implementation of a QMS requires well-defined processes and properly trained and competent
personnel that continually work to reduce or eliminate the deficiencies in each process. When an
organization implements a QMS, it will likely undergo a transformation where there is more
investment on the development of the key processes to prevent failures and rework. As shown in the
previous Figure, by shoring up the deficiencies in each of the key processes, a QMS will help a
project avoid costs by preventing fewer failures and less rework.
The Figure below is focused on rework and the return of investment of a QMS. It illustrates a
representative model of how an organization that implements a QMS will realize an overall cost
avoidance. The left chart shows a project without a well defined QMS and the chart on the right
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 6
shows a project with well defined QMS processes.
The pipeline industry is no different than any other industry that has implemented a QMS.
Predominately the return on investment realized has been equal to or greater than the cost of
implementing the QMS.
In pipeline construction, quality is often simply defined as conformance with specified requirements.
If a project conforms to the specified requirements, it will satisfy its customers. The customers of
pipeline construction projects include project sponsors, shippers and downstream customers,
regulators, landowners, the owner company’s internal departments, their construction partners (such
as, the external engineering firms and the construction contractors)and other special interest groups.
The following are the basic requirements for developing a pipeline construction QMS:
a. Identifying the processes needed for the QMS and their application throughout the multiple
organizations involved in the project.
c. Determining criteria and methods needed to ensure that both the operation and control of
these processes are effective.
d. Ensuring the availability of resources and information necessary to support the operation
and monitoring of these processes.
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 7
e. Monitoring, measuring, and analyzing these processes, and
A process is an activity that uses resources and is managed to enable the transformation of inputs
into outputs. The application of a system of processes within an organization, together with
identification and interactions of these processes, and their management, can be referred to as the
“process approach”.
Under a QMS, pipeline construction projects are completed in accordance with quality management
principles. The project is constructed utilizing a process approach, focusing efforts on planning,
procedures, provisions for effective documentation, document control, effective corrective actions
and continual improvement activities.
Within a QMS structure, written procedures are established for all significant construction activities.
Field inspectors have written instructions on what is expected of them. Construction specifications,
drawings and the contracts provide clear work output and records requirements. Processes are
audited to confirm conformance. Construction project goals typically involve delivering a project
that conforms to the desired specifications and, also, are delivered in a consistent and repeatable
manner. Conformity means the project meets customer, legal, regulatory, HS&E, Company
specifications and other defined requirements. Consistency means the business or project strives to
continually improve the effectiveness, efficiency and repeatability in which the project is delivered.
Both conformity and consistency goals are required to maximize the value attained by a QMS.
Furthermore, a QMS is a structured way of controlling the core processes of a project and is not just
focused on the end goals. By organizing, managing and continually improving the processes within
the QMS it will lead to the delivery of a better overall project. A key aspect of a QMS is the
documentation of procedures to support all the key processes to ensure a project’s QMS is
sustainable and is not dependent on certain people resources or infrastructure to function properly.
There are several common terms often used, and, sometimes misunderstood in the context of a QMS.
Quality Policy: Defines the goals and objectives of a QMS for a business or project.
Below is an illustration of a simple four step QMS process. Each core process identified within a
pipeline construction project follow these same repeatable steps. All four of these steps are required
and must be maintained to have a properly functioning QMS.
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 8
Step 1 – Plan the processes, products or services for your project.
Step 2 – Do the work to execute your project in accordance to your Plan
Step 3 – Check and measure to assure that activities within the project meet the desired
requirements and accomplish the project goals.
Step 4 – Act to continually improve all processes and strive in improving the delivery of the project.
Plan
Act / Do
Improve
Check &
Measure
For a QMS to work and deliver maximum results, it is important for an organization to establish the
appropriate degree of flexibility within the key and supporting processes and to have the right level
of documentation of records, procedures and reports. These are important considerations to ensure
that a QMS does not become overly complex and bureaucratic and become a reason why a project
does not achieve its goals. When a QMS is well designed it makes it easy to succeed and difficult to
fail.
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 9
Core Elements of a QMS
The following core elements are contained within both the ISO 9001 and the industry-specific ISO
29001 (API Q1) quality standards and are applicable to pipeline construction projects. There are
other additional elements that should be considered, but the elements described below are considered
core. By incorporating these elements into a QMS it ensures the key and supporting processes and
the interaction between processes will function as intended.
1. Management Commitment
All levels of management are involved and contribute to achieving an organization’s goals
and objectives.
Top down management is important to foster a culture that understands the value of a QMS
for pipeline construction projects.
Management ensures that proper infrastructure and resources are available to support the
QMS.
Management reviews the QMS on a regular basis to ensure it is functioning properly and to
ensure conformance to requirements.
2. Resource Management
Determine the necessary resources and information to implement and monitor the key
processes of a QMS. This also includes the people to manage the resources.
Qualified and competent people are available to support the QMS and the key processes
within. These people require appropriate experience and training to achieve the desired
level of qualification. People operating within the QMS are evaluated for performance and
continued competency.
Training programs including core and job specific requirements are established. Core
training is included within the QMS. In addition to job-specific training, each quality
critical position will have a written job description that describes the necessary educational
and work related experience to adequately perform the required tasks.
3. Plan and Develop Processes
Process Control
Identify and implement the processes and determine the interaction between them.
Establish the roles and responsibilities for controlling the processes and records.
Written procedures are established for all significant construction activities.
The field inspectors have written instructions on what is expected of them.
4. Measurement, analysis and improvement
Monitor, Measurement, and Analysis
Monitoring and measuring activities are conducted to ensure that key processes are
effective. For pipeline construction projects this would include the various inspection
activities.
Determine criteria and methods needed to ensure that both the operation and control of the
processes are effective. Monitor, measure, and analyze these processes.
Audits (Process Assessments)
Audits, sometimes called Assessments, are conducted to ensure the integrity and continual
improvement of work processes.
Audits may be are performed on planned intervals or on an as needed basis.
Through audits, non-conformances are identified and immediate actions are taken to
remedy these situations.
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices
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The following types of audits can occur within the operation of the QMS:
Internal Audits: Internal audit programs typically are established by the project owners to
ensure the integrity and continuous improvement of the work processes, including the
QMS.
Stakeholder Audits: Quality audits by various stakeholders are permitted and typically
require adequate notification to conduct.
Regulatory Audits
The business or project offers full cooperation to all regulatory audits to confirm
compliance with applicable regulatory requirements.
Continual Improvement
Non-conformances are identified and immediate actions are taken to remedy these
situations.
Corrective actions identified prevent the reoccurrence of similar non-conformances by
addressing and eliminating the root causes.
Lessons learned are shared with other project teams.
5. Documentation and Records
Establish the core documentation requirements and controls for the overall QMS, key and
supporting processes and procedures.
Includes documenting industry specifications and standards, inspection testing plans and
determining records that need to be maintained for the project.
All documents used on the project must be current and approved, and available for the users.
Documentation Control
QMS policies and procedures are maintained under document control, as are quality-critical
documents such as construction drawings and specifications, work processes, process maps
and procedures.
Documents required by the QMS are controlled. Written procedures are in place for
controlling document approval, revision of documents and document retention.
Records Control
Records are generated to confirm conformance and compliance with project requirements
and applicable regulations and codes. These are maintained in a secure environment for the
project. In the case of projects, records are part of the final turn-over to the owner for
operations.
Records are established and maintained to provide evidence of conformity and compliance
to demonstrate the effective operation of the QMS.
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Conclusion
Recent industry work has demonstrated that quality processes implemented in production
processes for plate, pipe and coating mills has been successful in producing products that
consistently meet requirements. The recommendation, based on the pipeline construction
quality issues, is to establish and implement a QMS for construction practices on the right-
of-way.
Implementing a QMS for pipeline construction projects does not guarantee flawless projects,
but provides a framework for consistently maximizing the quality of the overall project. This
framework should include provisions for training and qualification of specific construction
procedures, audits and corrective actions. Incorporating these elements at an early stage of
these processes will help to ensure project quality objectives are consistently met.
There are many ways to go about developing a QMS and Operators will have to decide what
works best for their organization.
ISO 9001 is a useful resource and ISO/TS 29001 (API Spec Q1) offers industry specific
guidance on the development of a QMS for the Oil and Natural Gas industries.
The following appendices provide examples of how a QMS can be applied to pipeline
construction projects (pipe coating and welding, a simple QMS for a pipeline construction
project and some alternate QMS models).
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Appendix A – Example Applications of the QMS Elements for Pipeline Construction Projects pertaining to Pipe Coating and Welding
1. Management Commitment 2. Resource Management 3. Plan and Develop Processes 4. Measurement, Analysis & 5. Documentation and Records
Improvement
Coating & Welding Coating Coating Coating Coating & Welding
Top-down support of the QMS provides a quality Equipment, specifications and Process to develop procedures that: Inspect to demonstrate conformance to Procedures and specifications are
culture that will motivate the team documented procedures are required. Clearly outline roles and responsibilities procedures and specifications documented for performance of work
Outline Owner Company’s requirements (Typically an engineering specification) Audit a sample of completed work. and inspection tasks
Training, qualification and re-qualification Specifications and procedures for the Specify Manufacturer’s application and storage requirements Take dry film thickness readings Training, qualification and re-
records are generated and maintained work and inspection of the work are Outline proper application equipment Adhesion tests qualification records are generated and
Adequate resources are verified and required Outline training of application and inspection personnel Audit training and qualification of coating maintained
maintained Training, qualification and re- Production method and repair methods and controls resources Resource qualifications are verified and
Inspection and non-destructive examination qualification of personnel Outline procedural changes to respond to changes in environmental and physical conditions Issue non-conformance reports and identify maintained
(NDE) records (as applicable) are created Required equipment verified and Environmental conditions for storage of the unapplied products corrective actions Inspection and NDE records created
and retained maintained Environmental conditions for the application of the products Follow through on corrective actions and and retained
Audit reports are created, retained and Audit personnel and procedures Environmental conditions for the curing of the applied product also evaluate effectiveness of corrective Audit reports are created and retained
analyzed Non-conformance report logs and Temperature control during application and cure actions NCR logs and corrective actions are
Non-conformance report logs and corrective Jeep, ACVG and DCVG tests recorded
corrective actions are recorded and Properties of the finished product – perhaps hardness, thickness, adhesion
actions are analyzed and are part of the Management of change to incorporate Document lessons learned
lessons learned process
managed Training of the QC personnel
improvements with processes, procedures,
Act on lessons learned etc., is established
Process and share lessons learned with
stakeholders
Note: Refer to the following White Papers at the INGAA Foundation for more information Field Applied Coatings and Welding best practices and procedures:
1. Training Guidance for Construction Workers and Inspectors: Welding & Coating, published 2012
2. Field Applied Coatings Best Practices, published 2012
The INGAA Foundation | Overview of Quality Management Systems Principles and Practices 13
Appendix B – Example of a Simple QMS
The following is an example of a framework of a QMS from a pipeline owner company. This Company
has established, documented and implemented a QMS as a means of ensuring that its pipelines and
facilities conform to specified requirements and to foster an environment of continual improvement.
The Company’s QMS is comprised of Core and Support Business Processes. Processes such as QP
4100and the others shown in the example below are available on the Company’s intranet site.
Core Processes:
The core processes describe all the processes that are necessary for the Company to realize and deliver the
desired service to its customers. QP 4100 is an overview of the processes and their interactions. The Core
Processes are listed below:
Support Processes:
The Company’s support processes describe all other business requirements that are necessary to manage
and control resources, and to conduct business in an orderly manner. They include:
Appropriate levels and types of monitoring and measurement of core and supplemental processes have
been determined and are documented within the relevant procedures. The criteria and methods required to
ensure the effective operation and control of these processes are defined and documented. This is
typically referred to as quality control (QC).
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The sequence and interaction of the Core and Support Business Processes are described by the QMS
planning provisions in QP4100. This is typically referred to as quality assurance (QA).
All QMS documentation and other key information necessary to support the operation and monitoring of
Company business processes are available to all employees, and other parties requiring access such as
consulting engineering firms, on the Company’s intranet.
The QMS includes policies and procedures for implementation of actions required to achieve planned
results, and for continual improvement of the business processes.
When non-conformance is observed, the Company assesses the consequences, applies immediate
correction, determines the root cause, and assures that the process is adjusted so that the non-conforming
condition is not created again in the future. Errors are traced back through the process that created them to
remove the cause of the error.
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Appendix C – Example QMS models
Two examples of QMS models are shown below that a pipeline construction project can adopt. These
models expand the concepts within the basic QMS model discussed previously (PLAN, DO, CHECK &
MEASURE and ACT/IMPROVE) along with highlighting several core elements. These models are still at a
high level and they further outline key processes and how they interrelate with one another. These
models incorporate the identification of requirements, goals and objectives of a project. These models
include processes for monitoring, measuring and analysis and the concept of continual improvement
and feedback. Feedback is a valuable process for consideration to improve the overall QMS to ensure
customers and stakeholders are satisfied with the results delivered.
Legal, EH&S
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Process Approach To Quality
Product
Requirements
Inputs Outputs
Product
Realization
C C
U U
S S
T T
Measurement,
O Resource O
M
analysis & M
Management improvement
E E
R R
Management
Responsibility
Feedback
Communication Input
Output
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