Corrective Action = Retraining?

Industry Outreach SeriesCORRECTIVE ACTION = RETRAINING?

By Stephen Massey February 2013

Copyright © 2013 Stephen Massey

Industry Outreach SeriesCorrective Action = Retraining?

Disclaimer: This presentation describes my personal viewpoints, not those of Elsevier, or any other company or government entity

Corrective Action = Retraining_130222.pptx

Introduction



PCA was shut down in 2009 after massive outbreak of Salmonella Typhimurium.

In the News: Former Peanut Corporation of America (PCA) officials face criminal indictments. Includes President, Operations Manager and QA Manager.

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.

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.

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

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


Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx

ComparisonRefresher 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


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

“Does my Contractor really understand problem causes?

“Retraining rarely prevents problem recurrence”

How might your Client view Retraining?



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


Take note of typical project landmine ingredients

Zooming-In Universal Project Landmine Symbol


Copyright © 2013 Stephen Massey Corrective Action = Retraining_130222.pptx

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).

https://dl-web.dropbox.com/get/Massey_Stephen_Public/8%20questions%20every%20senior%20leader%20should%20ask_Krause_0610.pdf?w=AACJdf5znToW0APPMqPY85nEMtqEaf2ZgnSPLtrQpd2VEw

No requirement to drill down into causesContributing Cause Boxes

“No need for evidence”Omits Causes

“Just fix the problem!”Single Root Cause Trap

“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




Perceived risk* after box-checking theSafety Near Miss Investigation (< 24 Hrs.)

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

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

* Before implementing weaker solutions that maintain perceived Probability at Low

RISK PERCEPTIONS CHANGE WHEN THE LANDMINES BECOME VISIBLE

SAME INVESTIGATION TEAM … SAME INCIDENT



… MUCH DIFFERENT OUTCOMES

Figure 1 mark-ups apply to this particular example


RETRAINING ≠ CORRECTIVE ACTIONRetraining will NOT prevent recurring problems

Sources


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



Sports AnalogyHow 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

As long as the Peanut Galleryavoids Salmonella-laced peanuts!

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


I appreciate and welcome comments and feedback!

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

Corrective Action = Retraining?

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