Page 181 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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150 Serious Incident Prevention

Managers frequently talk-the-talk regarding the need to find and correct
root causes. However, discussions often reveal a lack of consensus on what
“finding the root cause” really means. (Root cause is often defined by texts
as “the most basic reason[s] for a problem, which, if corrected, will prevent
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recurrence of that problem.”) Some managers seem interested only in trac-
ing causes back to the point where, in the mind of the manager, a person
could have taken action to prevent the incident. The incident is then classi-
fied as caused by human error, and corrective action is targeted to influence
behavior. Such an approach considers only the shallowest of roots. The or-
ganization becomes dependent upon superhumans who are expected always
to take the right compensating actions to circumvent conditions leading to
serious incidents.
When the potential consequences of a performance failure are serious,
the objective must be to implement corrective actions that will remain effec-
tive for decades. Solutions must be effective even when the organization’s
bottom-quartile performers are at the controls. Corrective actions must be in-
stitutionalized to withstand changes in supervision and other factors that im-
pact an organization over the long haul. Corrective actions with staying
power are usually those developed and implemented with employee input
and those with a performance measurement system in place for monitoring
progress. Table 13-5 summarizes guidelines for effective corrective actions.

TABLE 13-5
Guidelines for Effective Corrective Actions in
Sustaining Serious-Incident-Free Operations
Be Proactive
Promote individual/team involvement and ownership of the serious incident pre-
vention process
Investigate deficiencies reflected by critical work performance measures
Investigate near misses and other “red flags”
Strive for solutions not dependent upon the attention of best personnel or perfect
operating/administrative controls
Institutionalize corrective actions by integrating into documented procedures
and processes
Promote organizational mindset of continual improvement
Follow through when corrective action needs are identified
Be slow to fix blame, but be prepared to remove individuals from safety-critical
jobs as warranted