Tag: corrective action
There are a number of websites and political candidates touting the benefits of the Ready-Fire-Aim approach. Decisiveness is characterized as a virtue; hesitation as a sign of weakness.
Sometimes it is fatal.
The classic example of this is when a co-worker rushes into a confined space to save a buddy – and they both end up dead.
Most of the pundits favoring the Ready-Fire-Aim approach are focused on overcoming the negative impacts of inertia within an organization. They are seeking to address those situations within organizations where endless studies are conducted but action is never taken.
The want action and they want action NOW.
Inertia is a problem within many organizations that does need to be addressed. But simply focusing on taking action more quickly – speeding up the response – is not always the answer.
Prior to making changes, it is important consider the downside risks of the action being proposed.
One of the most commonly missed provision of OHSAS 18001 is the requirement in section 126.96.36.199 e) that the organization’s corrective action procedure define requirements for “reviewing the effectiveness of corrective actions taken.” This requirement is consistent with similar requirements in Section 4.5.3 e) of ISO 14001:2004 and Section 8.5.2 of ISO 9001:2008 and is often missed in quality and environmental management systems as well.
What this provision requires is that an organization have processes are in place to “circle back” at some later point in time to verify that the corrective actions taken actually worked.
What does this “effectiveness review” need to include?
At a minimum, two determinations are needed –
- Was the proposed corrective action done?
- Was the action taken “effective”?
First, was it done – was some action actually taken, was the action that was completed what was proposed and has it been sustained?
It is not uncommon to find that the proposed action was never done. Sometimes, people get “busy” and taking the specified corrective action is constantly “put off until tomorrow” as other priorities take precedence. In other cases, the action actually undertaken is NOT the action that was initially proposed. Perhaps the proposed action didn’t actually work when it comes to actually implementing it. Then there are the situations where changes are made initially but the organization quickly reverts to doing things the old way.
Second, was the action taken “effective” in fixing the issue identified as the nonconformity?
It is not uncommon to find that the action actually taken as corrective action bears little, or no, relationship to “the problem” identified as the nonconformity in the first place. In the process of evaluating what actions should be taken, it is easy to get sidetracked by other interests and priorities and end up “fixing” something else entirely. (“Gee, this is a great opportunity to justify getting the new training software we have always wanted.”)
The other difficulty with determining the effectiveness of the action taken is that “effective” is not a defined term and is a very subjective standard.
What qualifies as “effective”?
In a previous blog, I discussed that an incident is NOT the same as a nonconformity. An incident is a situation where some kind of harm occurs (or could occur); a nonconformity is defined as “non-fulfillment of a requirement”. There is often a relationship between the two – but not always.
Similarly, correction and corrective action are NOT the same.
These are defined terms that have been taken from the quality world and applied to EHS management systems. They are also an entrenched part of registration audits so it is important to understand how registrars define them (i.e. their ISO 9000 definitions). When registrars issue corrective action requests (CARs), they often request information on any corrections done as well as a description of the corrective action planned.
A correction is defined as “action to eliminate a detected nonconformity”. In the quality world, correction is often referred to as containment (as in preventing nonconforming product from reaching the customer). Correction in a QMS can consist of repair, rework, scrapping the product, etc. The first action taken is often segregation and control of non-conforming product.
This quality concept was incorporated into ISO 14001 as correction and mitigation – as in taking action to mitigate environmental impacts (see Section 4.5.3 a). The same concept was also incorporated into OHSAS 18001 as correction and mitigation – as in taking action to mitigate OH&S consequences (see Section 188.8.131.52 a).
In all the standards, the focus of correction is on the immediate fix.
A corrective action is defined as “action to eliminate the cause of a detected nonconformity or other undesirable situation.” A note to this definition in ISO 9000 states that “there is a distinction between correction and corrective action.” The distinction is the focus. In corrective action, the focus is on what CAUSED the nonconformity.
Since the focus of corrective action is on causation, some type of root cause analysis is a prerequisite to defining the appropriate corrective action.
© ENLAR® Compliance Services, Inc. (2011)
One of the key requirements of the OHSAS 18001 standard is establishing a procedure for taking corrective and preventive action (section 184.108.40.206). Both corrective and preventive action need to include identifying the underlying causes – often called root causes – of whatever it is that is or went wrong.
This is not easy. Often, the root cause investigation ends with a determination along the lines of “Joe screwed up.” We play the blame game.