110: Reactive Risk/Safety/Reliability/Quality/Security Analysis Issue
Definition/Typical Issues
Was an incident caused by failure to provide recommendations for known deficiencies or failure to implement recommendations before known deficiencies recur? Had the problem occurred before and never been reported? Did an investigation fail to identify the issue? Did the recommendations that were implemented fail to correct the problem?
Note 1: Reactive analyses are triggered whenever a deficiency is identified regardless of whether a loss or accident occurs. Reactive analyses also address information investigations and analyses.
Note 2: If the problem/deficiency could/should have been identified as part of a proactive analysis or was identified in a proactive safety/hazard/risk/reliability/quality/security review, then code the incident in that portion of the Root Cause Map™ (nodes #104-109) and not here.
Examples
Example 1
- An audit of the reliability program failed to identify that several surveillance activities had not been performed.
Example 2
- A gear tooth failure destroyed the gear train of a printing press. Only those gears with visibly damaged teeth were replaced because no recommendations were made to examine the adjacent gears. The press failed again about 6 months later when another gear tooth, overstressed but not visibly deformed by the first incident, failed.
Example 3
- A tank collapsed under vacuum. An earlier root cause analysis (completed due to a near miss) recommended vacuum breakers for this tank, but these devices had not yet been installed.
Example 4
- A tank had overflowed when the operator started the wrong pump. None of the pump control switches were labeled. A recommendation from this incident was to install labels on the pump switches. Prior to installation of the labels, another pump was damaged when the operator started the wrong pump. The switches for these pumps were not labeled either.
Typical Recommendations
- Track implementation of recommendations to ensure timely completion.
- Consider implementing the same recommendations for similar situations at this and other facilities.
- Measure the effectiveness of recommendations.
- Periodically compare the results of audits with incidents that occur in the facility to ensure that audits are effective in identifying problems.
- Establish and implement written procedures to report on, collect data related to, investigate, and learn from incidents.
- Assign a job function as the champion of the incident investigation process.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 78 | Problem Identification/Control |
| PSM Element(s) |
|---|
| 14 |
| RBPS Element(s) |
|---|
| Incident Investigation |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 89 | Problem Identification/Control Issue |