Corrective Action = Retraining?

Industry Outreach Series
CORRECTIVE ACTION = RETRAINING?

By Stephen Massey February 2013

Disclaimer: This presentation describes my personal viewpoints, not those of Elsevier, or any other company or government entity
Corrective Action = Retraining?
Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx

Introduction
In the News: Former Peanut Corporation of America
(PCA) officials face criminal indictments. Includes
President, Operations Manager and QA Manager.
PCA was shut down in 2009 after massive outbreak
of Salmonella Typhimurium.

A customer notified PCA on 5 October 2006: A PCA product tested positive for Salmonella.

And from 6 October 2006 forward, PCA implemented a flawed corrective action path.
Consequently, the problem snowballed into a major crisis.

Executives and managers read these stories and think, “It can’t happen to me”.

Unfortunately, many are unknowingly engaged—right now—in flawed corrective action paths.
Their flawed corrective action paths commonly start with their own ISO-compliant documentation.
My objective: Help you easily recognize, measure and avoid the most common SYMPTOM of a
flawed corrective action path: Retraining—the preferred corrective action.


Where’s your project on the Retraining Meter?

High risk projects operate in the red zone
Red zone projects have recurring safety incidents, recurring operational
problems, recurring rework, recurring data quality problems,
recurring environmental impacts, etc.


Where were these projects on the Retraining Meter?

The Retraining Meter was most likely in the red zone

Comparison
Refresher Training | Retraining

Unclear on Retraining? If so, this table will help.


Sample Retraining Metric

• The Retraining Metric is a leading performance indicator for recurring problems
• High Project Retraining Ratio indicates high probability of recurring problems
• When does project enter Red Zone? .67? .75? That’s your decision.
Recommendation: Visit your project (or project website), identify record types,
tally your score, and baseline your reliance on Retraining.


Recognize the Retraining Quick Fix Rhetoric?

“Our project experienced a serious
problem or near miss”

“The problem was caused by an individual
who was previously trained”

“We retrained the individual and staff,
with sign-offs for accountability”
Did you remember to visualize the person making these
statements with an aura of seriousness and self-confidence?

RETRAINING … IS THE PATH OF LEAST RESISTANCE


How might your Client view Retraining?

“Predictable Contractor response soon after a
near miss, incident, or performance issue”

“Does my Contractor really understand problem
causes?

“Retraining rarely prevents problem recurrence”

Clients want their PM to take responsibility…
NOT BLAME OTHERS OR APPLY BANDAIDS


Recurring problems become epidemic when …
“Retraining” is the preferred corrective action

Underlying causes remain hidden like invisible landmines


Zooming-In
Universal Project Landmine Symbol

Take note of typical project landmine ingredients


Would Retraining prevent problem recurrence?

ANSWER: NO … AND THE NEXT SLIDE FEATURES FORMS THAT COMMONLY OMIT CAUSE ANALYSIS

* Krause D.R., Groover, D.R., Martin, D.K., (June 2010), Preventing Incidents and Fatalities: 8 Questions Every
Senior Leader Should Ask (Q.7/8). Professional Safety, Journal of the American Society of Safety Engineers (Link). Industry Outreach Series

No requirement to drill down into causes
Contributing Cause Boxes Omits Causes Single Root Cause Trap
“No need for evidence” “Just fix the problem!” “The root cause is human error”

Safety Investigation Report Nonconformance Report Corrective Action Request
These OHSAS 18001/ISO-9001 compliant forms lure teams into The Retraining Quick Fix
Corrective Action Path: “Just fix the problem, retrain employees and move on …
and don’t forget to complete each box so we pass the next regulatory inspection and ISO audit”

So What Happens When a Team Analyzes and Documents Causes?

No Cause
Categories

Avoid “Single
Root Cause”
Tunnel Vision

No Blaming
Individuals

Emphasis on
Evidence

Project Team
Maximizes
Solution Options
to Prevent
Recurrence


SAME INVESTIGATION TEAM … SAME INCIDENT
… MUCH DIFFERENT OUTCOMES
Perceived risk* after box-checking the
Safety Near Miss Investigation (< 24 Hrs.)

Figure 1 mark-ups apply to this particular example
* Before implementing weaker solutions that maintain perceived Probability at Low

Perceived risk* after charting the
Root Cause Analysis* (< 72 Hrs.)

* Before implementing stronger solutions that shift perceived Probability to Low or Negligible

RISK PERCEPTIONS CHANGE WHEN THE LANDMINES BECOME VISIBLE Industry Outreach Series

RETRAINING ≠ CORRECTIVE ACTION
Retraining will NOT prevent recurring problems
Don’t get lured into the Retraining Quick Fix …
Learn how to drill-down into causes to identify effective solutions

Take Action Now: Re-assess significant project performance
problems that primarily relied upon Retraining Corrective Actions

Sources


Sports Analogy
How NFL Coaches Decrease Risk of Penalties

CHALLENGE FLAG TRIGGER: TIMEOUT … LOOK AT CAUSAL EVIDENCE BEFORE YOU PENALIZE
SOMEONE … DON’T JUST FOCUS ON THE LAST GUY WHO REACTED TO A CAUSE.

Presentation Recap &
Project Risk Reduction Roadmap

A lot of detail here … but this is your risk reduction roadmap


Contact Info

Thank you for sharing
this presentation with your project team

I appreciate and welcome comments and feedback!

As long as the Peanut Gallery
avoids Salmonella-laced peanuts!

http://en.wikipedia.org/wiki/Peanut_gallery


Corrective Action = Retraining?

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