108: Recommendation Implementation Issue
Definition/Typical Issues
Was there a failure to implement the recommendations from the safety/hazard/risk/reliability/quality/security review? Was there a problem in implementing the recommendations from the safety/hazard/risk/reliability/quality/security review? Was there a failure to assign the recommendation to a specific individual? Did management fail to monitor the implementation of recommendations?
Typical analyses addressed by this node include:
- Process hazard analyses
- Hazard and operability analyses
- Reliability analyses
- Security vulnerability analyses
- Failure modes and effects analyses
- Reliability-centered maintenance analyses
- Enterprise risk management analyses
- Project risk management analyses
- Fault tree analyses
- Event tree analyses
- Probabilistic risk assessments
- Job safety analyses
Examples
Example 1
- A release of hazardous material through a rupture disk was discharged to the diked area of the process. The hazard review had recommended installing a catch tank, with a rain hood/cover, to receive any discharged material. The catch tank had not been installed because of scheduling conflicts with other construction in the area. The released material reacted violently with rain water in the diked area, producing a large quantity of toxic gas.
Example 2
- As a result of a facility risk/reliability analysis, recommendations were made to have a final inspection performed of unusual and partial shipments to ensure that they are correct. This recommendation had not been implemented yet. As a result, a partial shipment was sent to a customer that was incorrect.
Typical Recommendations
- Update the tracking system daily, weekly, or monthly, as appropriate, by adding new action items and/or documenting the current status of all action items.
- Conduct periodic, unannounced audits to verify that those action items documented as "complete" are actually complete.
- Prioritize action items and assign realistic dates for completion.
- Ensure that all hazard review recommendations are documented and reviewed by management personnel.
- Management should address all hazard review recommendations and document the manner in which the recommendation will be resolved (i.e., assign a responsible party for completion or reject the recommendation with documented reason for doing so).
- Communicate hazard review recommendations to all affected parties.
- Document the final resolution or implementation of each recommendation.
- Publish periodic reports of resolution status for management.
- Ensure that implementation of the recommendations is assigned to a specific group or individual.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 75 | Recommendations Not Yet Implemented |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 86 | Recommendations Not Yet Implemented |