113: Recommendation Identification Issue
Definition/Typical Issues
Were recommendations unsuccessful in preventing recurrence? Should other recommendations have been identified? Did the actions fail to address the causes and consequences identified in the analysis?
Note 1: This node addresses situations where the analysis identified the correct causes of the problem but incorrect or ineffective recommendations were specified. Situations where the incorrect causes have been identified are addressed by the Investigation Issue (#112) node.
Examples
Example 1
- A problem with operators bypassing alarms had been identified. The recommendation from the root cause analysis was to administratively control alarm bypasses. After a couple of years, the administrative control requirements were being ignored. Physical changes to equipment may have been a more successful approach for preventing the bypassing of alarms.
Example 2
- During a root cause analysis, personnel developed 15 recommendations. Some of the recommendations addressed issues that were tolerable to the organization. In addition, no recommendations were developed to address some other unacceptable risks. As a result, resources were dedicated to addressing some risks that were already acceptable, and some unacceptable risks were not addressed.
Example 3
- 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 generated 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.
Typical Recommendations
- Involve a multidisciplinary team in identifying recommendations to ensure that the problem has been fully analyzed.
- Refer design/development of recommendations to specialists when teams have difficulty identifying practical solutions.
- Develop measures to determine the effectiveness of recommendations.
- Trend incident causes and root causes to determine whether recommendations are effective in preventing recurrence.
- Provide training to incident investigation team leaders and team members.
- Provide a suggestion box in the facility.
- Review contractor incident and near-miss investigation practices and reports.
- Develop appropriate recommendations for each cause.
- Require the investigation team to specifically show the relationship between the incident, the causes, and the recommendations identified.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 83 | Corrective Action LTA |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 93 | Corrective Actions Ineffective |