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Corrective Action = Retraining?

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TRANSPARENCY Employee Near Miss Preventable Fatality DEATH INVESTIGATION Corrective ACTION Training Retraining Project MANAGEMENT Problem SAFETY accident engineering investigations bias BIASED …

TRANSPARENCY Employee Near Miss Preventable Fatality DEATH INVESTIGATION Corrective ACTION Training Retraining Project MANAGEMENT Problem SAFETY accident engineering investigations bias BIASED reporting NONCONFORMANCE NCR corrective action LEADING lagging process indicators CONTINUOUS IMPROVEMENT METRICS ISO-14001 ISO-9001 OHSAS-18001 OSHA 200 Log Recordable Injury NQA-1 EPA ASQ E4 10 CFR 830.120 BMP Root Cause and Effect ANALYSIS Charting mapping QC Checklist systemic PMBOK Risk Management preventing RECURRING ADVERSE events Outcomes Patient HARM Trend Analysis PREVENT RECURRANCE reliability SYSTEM DOWNTIME Outages

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  • 1. Industry Outreach Series CORRECTIVE ACTION = RETRAINING? By Stephen Massey February 2013Disclaimer: This presentation describes my personal viewpoints, not those of Elsevier, or any other company or government entity Industry Outreach Series Corrective Action = Retraining? Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 2. 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. Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 3. 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. Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 4. Where were these projects on the Retraining Meter? The Retraining Meter was most likely in the red zone Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 5. Comparison Refresher Training | Retraining Unclear on Retraining? If so, this table will help. Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 6. 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. Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 7. 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 Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 8. 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 Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 9. Recurring problems become epidemic when … “Retraining” is the preferred corrective action Underlying causes remain hidden like invisible landmines Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 10. Zooming-In Universal Project Landmine Symbol Take note of typical project landmine ingredients Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 11. 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 Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 12. 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 RequestThese 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” Industry Outreach Series Corrective Action = Retraining? Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 13. 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 MaximizesSolution Options to Prevent Recurrence Industry Outreach Series Corrective Action = Retraining? Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 14. 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 NegligibleRISK PERCEPTIONS CHANGE WHEN THE LANDMINES BECOME VISIBLE Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 15. 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 Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 16. Sports Analogy How NFL Coaches Decrease Risk of PenaltiesCHALLENGE FLAG TRIGGER: TIMEOUT … LOOK AT CAUSAL EVIDENCE BEFORE YOU PENALIZESOMEONE … DON’T JUST FOCUS ON THE LAST GUY WHO REACTED TO A CAUSE. Industry Outreach Series Corrective Action = Retraining? Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 17. Presentation Recap & Project Risk Reduction Roadmap A lot of detail here … but this is your risk reduction roadmap Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
  • 18. 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 Industry Outreach Series Corrective Action = Retraining?Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx

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