Weitere Àhnliche Inhalte
Ăhnlich wie Corrective Action = Retraining? (20)
KĂŒrzlich hochgeladen (20)
Corrective Action = Retraining?
- 1. 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
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, âIt canât happen to meâ.
Unfortunately, many are unknowingly engagedâright nowâin 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: Retrainingâthe preferred corrective action.
Industry Outreach Series
Corrective Action = Retraining?
Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
- 3. Whereâs 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
âą The Retraining Metric is a leading performance indicator for recurring problems
âą High Project Retraining Ratio indicates high probability of recurring problems
âą When does project enter Red Zone? .67? .75? Thatâs 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?
âOur project experienced a serious
problem or near missâ
âThe problem was caused by an individual
who was previously trainedâ
âWe retrained the individual and staff,
with sign-offs for accountabilityâ
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?
âPredictable Contractor response soon after a
near miss, incident, or performance issueâ
âDoes my Contractor really understand problem
causes?
âRetraining rarely prevents problem recurrenceâ
Clients want their PM to take responsibilityâŠ
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 âŠ
âRetrainingâ 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
âNo need for evidenceâ âJust fix the problem!â âThe root cause is human errorâ
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: âJust fix the problem, retrain employees and move on âŠ
and donât forget to complete each box so we pass the next regulatory inspection and ISO auditâ
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 âSingle
Root Causeâ
Tunnel Vision
No Blaming
Individuals
Emphasis on
Evidence
Project Team
Maximizes
Solution 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 Negligible
RISK PERCEPTIONS CHANGE WHEN THE LANDMINES BECOME VISIBLE Industry Outreach Series
Corrective Action = Retraining?
Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx
- 15. RETRAINING â CORRECTIVE ACTION
Retraining will NOT prevent recurring problems
Donât get lured into the Retraining Quick Fix âŠ
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 Penalties
CHALLENGE FLAG TRIGGER: TIMEOUT ⊠LOOK AT CAUSAL EVIDENCE BEFORE YOU PENALIZE
SOMEONE ⊠DONâT 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