171: Training/Personnel Qualification Issue
Definition/Typical Issues
This major root cause category addresses issues related to the training and qualification of personnel, including all training that is the responsibility of the company to provide to company personnel, contractors, and third-party personnel.
Was there a failure to provide training on the task? Was the training insufficient to perform the task? Did the training fail to correspond to the actual work environment?
Examples
Example 1
- A solvent tank overflowed because the operator had not been trained on how to calculate liquid levels of tanks. Training was not required because it was assumed to be a "skill of the trade." However, the operators were not experienced with solvents and solutions with specific gravities less than water.
Example 2
- Management decided to only train one mechanic to repair a special digital processor used in the lab. However, while this mechanic was on vacation, the digital processor broke and another mechanic had to fix it. The untrained mechanic broke several other parts of the processor during her "repair" work.
Typical Recommendations
- Provide training in the hazards of the process and job tasks.
- Provide refresher training on appropriate tasks.
- Solicit comments from the trainees after they have been on the job for 3 months to identify "holes" in the training program.
- Ensure that instructors are properly qualified.
- Provide training on tasks critical to safety, reliability, and quality.
- Develop a formal training policy.
- Develop a written procedure for managing the training management system that describes the process for creating, updating, and maintaining training materials.
- Include specific roles and responsibilities in the management system procedure governing training.
- Review incident investigation results and correct any root causes related to training program deficiencies.
- Establish and promote an environment that encourages workers to develop a thorough understanding of their process.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 163 | Training |
| PSM Element(s) |
|---|
| 14 |
| RBPS Element(s) |
|---|
| Training and Performance Assurance |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 178 | Training/Personnel Qualifications |
| 193 | Emergency Preparedness Training Issue |
| 194 | Special Operations Training Issue |