The Achilles’ Heel of Corrective Actions: Ensuring Accountability and Effectiveness Across All Functions”

Good to be back after a month, I was away due to my 27 year old neice passing away at Sohar,Oman, thus the family was in mourning. Also I was away on business travel for a week.

#207

In many organizations, the process of closing corrective actions—whether arising from audits, assessments, inspections, or stakeholder engagements—is often treated with a surprising level of casualness. This lack of rigor not only diminishes the effectiveness of the corrective actions but can also lead to catastrophic outcomes. This issue transcends departments, affecting not only Safety-EHS but also Quality, Operations, HR, and more. When corrective actions are not taken seriously, the consequences can be severe, as tragically demonstrated by the Du Pont Belle West Virginia Phosgene gas fatality, where corrective actions remained open for over a dozen years, with records and systems bypassed or checked off without proper verification.

Corrective actions are meant to be more than just a check-the-box exercise. They require careful planning, dedicated ownership, and stringent tracking to ensure they are closed effectively and on time. Unfortunately, this is where many organizations falter. The lack of a systematic approach to closing these actions often leads to recurring issues, regulatory non-compliance, and in worst-case scenarios, loss of life.

It’s frustrating how something as straightforward as closing corrective actions often gets mishandled, especially when the stakes are so high. Despite being a seemingly simple task, many sites fail miserably at it. This is especially true in contexts where a more relaxed attitude towards compliance and safety can creep in, such as in India. Here are some key reasons why this happens, and why they should serve as warning signs for any organization:

Why Do Sites Fail in Closing Corrective Actions?

1. Lack of Commitment: At the heart of the problem is often a lack of commitment from the individuals responsible for executing the corrective actions. When there isn’t a genuine belief in the importance of these tasks, they become easy to ignore or half-heartedly complete.
2. Lack of Ownership: Without clear ownership, corrective actions can fall into a gray area where everyone assumes someone else is taking care of it. This lack of accountability leads to delays, incomplete actions, or, in the worst cases, actions that are completely forgotten.
3. Time Pressure: In many organizations, especially those in fast-paced industries, there’s constant pressure to meet production targets, deadlines, and other immediate goals. This often results in safety and compliance tasks being pushed to the back burner. The mindset of “we’ll get to it later” can be dangerous and counterproductive.
4. Taking It for Granted: There’s a pervasive attitude in some places where people assume that no one is really going to check whether corrective actions have been properly closed. This assumption breeds complacency, with people checking off actions as “done” without actually completing them. This is a significant risk factor, particularly in cultures where inspection and enforcement may not be as rigorous as they should be.
5. Reactive Mindset: A “we’ll deal with it when something happens” attitude is alarmingly common. Instead of proactively addressing potential issues, there’s a tendency to wait for an incident to occur before taking action. This reactive approach is not only dangerous but also completely undermines the purpose of corrective actions, which is to prevent incidents in the first place.

Warning Signs to Watch For

Organizations must be vigilant about these warning signs, as they can indicate a culture that is prone to failing at corrective action closure:

• Repeated Delays: If corrective actions are consistently being delayed or extended without valid reasons, it’s a clear sign that there’s a lack of priority being given to them.
• Incomplete Documentation: If the evidence of closeout is often missing or incomplete, it suggests that actions are being closed in name only, without actually addressing the underlying issues.
• Low Engagement from Leadership: When site leaders are not involved in validating or auditing closed corrective actions, it signals a lack of seriousness at the top, which will inevitably trickle down through the ranks.
• Complacency in Compliance: If the culture of the organization leans towards “checking the box” just to satisfy external requirements, without a genuine commitment to safety and quality, this is a major red flag.
• MS-Excel as tool to track progress: This is a clear present Danger as tracking tool as dates, macros can fail to work,causing havoc.

By recognizing these signs and addressing the underlying causes, organizations can strengthen their corrective action processes and ensure that they are truly effective. It’s not just about ticking off tasks; it’s about creating a safer, more compliant, and more resilient organization.

The Critical Elements of a Successful Corrective Action Plan

1. Clear Ownership: Every corrective action needs a designated owner. This person is responsible for ensuring the action is completed on time and to the required standard. Without clear ownership, actions often fall through the cracks, leading to incomplete or ineffective resolutions.
2. Defined Target Dates: Setting a realistic target date is essential. This creates a sense of urgency and helps in tracking the progress of the action. It’s important to ensure that no corrective action or its intermediate steps have a duration exceeding 60 days. Procrastination or excessively long timelines can dilute the effectiveness of the corrective action and lead to compounded issues.
3. Categorization of Actions: Not all corrective actions are created equal. Categorizing them can help prioritize and allocate resources appropriately:
   • CAT 1 (Simple to Do): Actions that are straightforward and can be closed quickly.
   • CAT 2 (Difficult to Do): Actions that are more complex and require additional time, resources, or expertise.
   • CAT 3 (Beyond Site’s Paygrade): Actions that cannot be closed at the site level due to their complexity or the need for higher-level intervention. These should be escalated to senior leaders for resolution.
4. Documenting Evidence of Closeout: To ensure that corrective actions are genuinely closed, there must be visual evidence and other forms of documentation within the system. This not only provides proof of closure but also serves as a reference for future audits and assessments.
5. Validation and Audit of Closed Actions: A key aspect often overlooked is the need to validate the effectiveness of closed corrective actions. At least 5% of closed actions should be audited or validated by site leaders / Top Leadership,to ensure they have been completed effectively and have addressed the root cause of the issue.
6. Horizontal Deployment: Lessons learned from corrective actions should not be confined to the site where they originated. They should be horizontally deployed across the organization to prevent similar issues from arising elsewhere. This ensures a proactive approach to risk management and enhances overall organizational resilience.

Conclusion

The process of closing corrective actions should be treated with the seriousness it deserves. It’s not just about fixing what’s broken—it’s about preventing future issues, ensuring compliance, and safeguarding the organization against potential catastrophes. By implementing a structured approach with clear ownership, realistic timelines, effective categorization, thorough documentation, and regular validation, organizations can ensure that corrective actions are not only closed but closed effectively. The stakes are too high to take this process lightly.

Good luck and let me know your comments

Karthik

4th Sep 2024.