One of the most challenging elements of any Safety Management System to adequately get right is corrective and preventative action. To develop a procedure on how an organization is going to address incident investigation, root cause analysis, implementing effective corrective action is not as easy as it sounds. Finding the actual root cause; primary and secondary, of an incident or audit findings can be debated, questioned and challenged in so many ways from an internal or external auditor’s point of view that it can cause a migraine. In a sense, corrective and preventative actions have to be proven by evidence that they have been verified for effectiveness and that the action taken mirrors addresses the root cause.
This is where many organizations struggle with compliance of this element.
This Safety Management System element requires procedures for an organization to act upon on non-conformances identified in the Safety Management System, including corrective and preventive action. A non-conformance is explained as the current condition of compliance is not in accordance with the Safety Management System.
An example of a nonconformance would be an employee not following a procedure. Another would be not meeting regulatory compliance. A near miss event or even an injury should be considered a non-compliance. Non-conformances may be identified through audits, monitoring and measurement, communications and incidents of any severity. The intent of documenting a nonconformance is to correct the system deficiencies by addressing root causes.Too many times, an employer can get stuck on just fixing the immediate result of an incident or audit finding only and do not take the time to find the primary let alone the secondary root causes.
Here are more examples of nonconformance
- Safety Management System 3rd party registration audits or surveillance audits;
- Reports / Inspections by Facility Personnel;
- Reviews of Safety Permit Conditions;
- Facility Monitoring Data;
- Reports/Complaints by Interested Parties (neighbors, contractors, visitors)
CORRECTIVE AND PREVENTIVE ACTION
The procedure that an organization develops should address how they will tackle corrective and preventative actions as well as to ensure that non-conformances are not only addressed to mitigate or minimize safety impact; but that further investigation occurs to determine theroot cause of the nonconformance. Also, the procedure should statehow the organization will take the necessary action to avoid the nonconformance from reoccurring.
Preventive actions are considered to be those actions resulting from an evaluation as to why nonconformities are occurring and taking action to prevent their recurrence.
This element also requires the employer to conduct a trend analysis in corrective actions to be evaluated in order to find out if deeper-rooted preventive actions can also be implemented. Constant review of this trend analysis will reveal where the organization must utilize its resources and prioritize activities.
In conclusion, it is important for an organization to be fully committed to continuous improvement within their Safety Management System. This element will truly demonstrate rather or not that is occurring. Remember to focus on recording the results of corrective actions that have been taken, and review the effectiveness of each individual action that has been taken. Doing so will not only sustain your Safety Management System, it will drastically improve the safety of your workforce.