April 21, 2007 | Mark Paradies

Implementing Corrective Actions – The Good and the Bad

You’ve worked hard at conducting a detailed investigation, making sure you’ve gathered all the evidence you need, defining your causal factors, and conducting the root cause analysis. You used the Corrective Action Helper® to give you a hand developing good, solid, useful corrective actions. You’ve verified that they meet the SMARTER requirements, and now it is time to implement those fixes. This final step can go in two directions:

1. You present the corrective actions, and management is on board. You receive the resources you need, and you can be confident that the incident will not happen again.

2. You present your corrective actions, and management decides that they are not obligated to implement them. They dispute your findings, and nothing is fixed. The entire investigation was a waste. Resources dedicated to your investigation would have been better used figuring out what you will do when the incident occurs again (which it probably will).

These two scenarios arrived in my email from the Chemical Safety Board yesterday.

1. In the first report, the CSB commends Kellogg, Brown, and Root (KBR) for exceeding the CSB’s recommendations for correcting an incident at one of their facilities last year. Corrective actions were developed and implemented, and this problem will not happen again.

2. In the second report, the CSB’s investigation of another company’s incident had to be closed with their response as “unacceptable.” In this 2002 incident, a fire broke out, resulting in one hundred nearby residents evacuated, a local school being closed, and significant environmental cleanup necessary due to firewater runoff. The facility was destroyed and never rebuilt. Here is a case where an enormous amount of resources was dedicated to the investigation, but the company decided to dispute the findings, with basically nothing being done to prevent another occurrence.

It can be frustrating when you conduct an investigation and have to fight for the resources to implement corrective actions. However, it is worth the struggle to prevent a recurrence of a serious incident.

Root Cause Analysis
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