114: Recommendation Implementation Issue
Definition/Typical Issues
Was a recommendation for a known deficiency not implemented (because of delays in funding, delays in project design, normal length of implementation cycle, tracking deficiencies, etc.) before recurrence of the deficiency? Did the actions fail to address the causes and consequences identified in the analysis? Was there a failure to assign the recommendation to a specific individual? Did management fail to monitor the implementation of recommendations?
Examples
Example 1
- A tank collapsed under vacuum. An earlier root cause analysis of a near miss recommended vacuum breakers for this tank, but these devices had not yet been installed.
Example 2
- A root cause analysis of a quality problem recommended that special orders be packaged in different-colored barrels to highlight the need for special handling. Since this recommendation was made, 16 more instances of mistakes with special orders occurred. The recommendation had never been implemented.
Example 3
- An incident investigation recommended that small drain holes be drilled in the discharge line of all fire monitors to prevent accumulation of water that could freeze and plug the monitor. This recommendation had not been implemented before another fire occurred, and two of the three monitors failed because they were plugged with ice.
Example 4
- An audit recommended shape-coding of certain controls on the control panel to avoid selection errors. This recommendation had not been implemented when another batch of product was ruined as a result of an operator switch selection error.
Example 5
- A number of action items had been generated from root cause analyses and process hazard analyses. The facility tracked the open items using a simple document table. Only one person had access to the table. As a result, it was difficult for managers to identify which actions were assigned to them.
Example 6
- The procedure development process was modified, based on an investigation, to ensure that precautions and warnings were placed in procedures where appropriate. However, an audit of procedures performed a year later identified hundreds of procedures that did not have the proper precautions and warnings.
Example 7
- An investigation team recommended a modification to a part inspection process to allow different types of defects to be identified. However, the recommendations were never implemented. As a result, unacceptable products were shipped to customers.
Typical Recommendations
- If a system is deficient and requires recommendations that cannot be implemented immediately, interim measures should be taken (implementing a temporary operating procedure, process parameter changes, shutting equipment down, etc.).
- The cost of implementing recommendations with significant impacts on reliability and quality should be balanced against the anticipated savings from implementation.
- Ensure that management periodically reviews the status of recommendations.
- Reward personnel for completing recommendations.
- Communicate the results of incident investigations to appropriate personnel.
- Implement recommendations to address contractor safety performance problems, as required.
- Establish a system to promptly address and resolve the incident report recommendations. Resolutions and recommendations are documented and tracked. A database is usually required to track the status of each recommendation.
- Review the status of each action item on a periodic basis, including review and approval of changes to the implementation plan/schedule (reasons for slips in the implementation schedule or significant changes to the scope of actions should be valid and well documented).
- Review the status of action items and conformance to the plan/schedule on a periodic basis with upper management.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 84 | Corrective Actions Not Yet Implemented |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 94 | Corrective Actions Not Implemented |