Page 179 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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148 Serious Incident Prevention

Corrective Action

Corrective action is universally recognized as a necessary management
responsibility, but the subject seems largely ignored in “how-to-manage”
publications. Perhaps the subject is considered too mundane to merit com-
prehensive discussion. Experience indicates, however, that corrective action
is a vital part of the serious incident prevention process. An organization’s
approach to corrective action significantly impacts its long-term capability
for sustaining incident-free operations.
Successful corrective action must be implemented proactively, prior to
the occurrence of failures with major consequences. Such proactive correc-
tive action is made feasible only through the existence of effective meas-
urement and feedback systems for upstream indicators of performance.

Addressing Causal Factors

When the organization has the right measurement systems in place, de-
teriorating performance in the safety process will begin to be reflected in
the measurement of upstream performance indicators during the formative
stages of problems. Deteriorating performance for key measures often re-
flects problems in one of the nineteen general categories of causal factors
4
leading to incidents. These causal factors, described in more detail in
Chapter 8, can be a starting point for identifying root causes of problems.
Causal factors include:
Human Factors:

1. Verbal communication
2. Written procedures and documents

3. Man-machine interface
4. Environmental conditions
5. Work schedule

6. Work practices
7. Work organization/planning

8. Supervisory methods
9. Training/qualification
10. Change management

11. Resource management