Root Cause Analysis Tips – Using Safeguards for Development of Corrective Actions
In our courses, we teach the use of Safeguards in Step 3 (defining causal factors) and in Step 6 (developing corrective actions) of the TapRooT® 7 Step process.
I wanted to talk a little bit about Step 6 today. If you have been to one of our courses, you have seen this. If you have not but are in safety or IH, you are probably familiar with the hierarchy of controls.
Let’s start at the top. I’ll use a fictional workplace/examples:
“Removing the hazard” altogether is the best option, but it is not always possible. For example, your company, Company XYZ has a business process involving hazardous chemicals, and you have been doing this process for 20 years with no problems. One day, employees are exposed and several are sent to the hospital….a bad day at XYZ. We would like to remove the hazard, but if we do, what happens? Well, unfortunately XYZ goes out of business. Even the most hard-nosed safety people would not suggest that! But what if over that 20 year period a chemical has been developed that would perform the same process but is less hazardous to employees? You could make the switch, and that would be an example of “reducing the hazard.”
10 years ago, XYZ hired Joe Sixpack, but we had nowhere for him to sit, so we built a cubicle in the corner of the warehouse. There is no reason for where we put him, it was just an open space that looked good at the time. Unfortunately, 5 years ago we located a hazardous process near his cube, and today he got exposed….yet another bad day at XYZ. If we move his cube, that is an example of “removing the target.”
Yesterday, we hired Speed Racer as our new ace material handler. His “get aquainted tour” included an unannounced visit to see Joe…..on his forklift. Opps. We don’t have a place to move Joe, but we decided to put up a Jersey Barrier in the warehouse around Joe’s cube. That would be an example of “guarding the target.”
From there, we move into “good human factors design,” which is always a good idea. But then, we get into rules, procedures, signs, supervision, and training, which I don’t need to explain, but are the weakest of the methods to prevent problems. The other day I made that statement in a course and a training manager was aghast, and I felt really bad for him, but it’s true.
Where do your corrective actions fit into this hierarchy? Take out a stack of old reports and you just might be surprised.
One of our clients actually developed a policy around this issue, and if an incident reaches a certain severity/frequency, the corrective action must be a 1-3 or it requires VP approval. That is a great best practice.
If you happen to be attending the VPPPA (Voluntary Protection Program Participant’s Association) Conference this month, I will be doing a talk about Safeguards on Wednesday the 26th @ 10:30. Stop by our Booth (#503) and see us!
And while we are on the topic of corrective actions, one of our contract instructors, Ken Turnbull, has some rules of thumb for spotting weak corrective actions:
Can’t Close (assure, insure, ensure), example; Ensure employees follow procedure.
Pass the Buck (review, recommend, study), example; Recommend safety department review xyz policy.
Hidden Discipline (remind, review with, counsel, make present), example; Remind employees to work safely. Have Joe present the incident in staff meeting.
This blog is a call to action; corrective actions are the OUTPUT of your investigation. If you have weak corrective actions, the rest of your work is meaningless.
Thanks for visiting the blog and have a good rest of the summer.