All great Safety Management Systems of my time have been built on the Plan-Do-Check-Act (PDCA) model. And although all of the stages of this PDCA model play a crucial role in the success of the SMS, the one that is most often overlooked is the CHECK stage. This CHECK is intended to validate/verify the SMS activities are generating the results we desire. Many will associate the CHECK stage with the traditional OSH/PSM auditing, and yes, these traditional audits do fall into the CHECK stage. But I want to talk about how the CHECK stage is also used to validate/verify the successful closing of Corrective Action Plans (CAPs). As we have discussed before, a well-oiled SMS will IDENTIFY a lot of opportunities to improve, and these opportunities will result in formal CAPs. And in a mature SMS, these Corrective Actions can be in the thousands, leading to people “freaking out” – especially when the closure rate(s) is a LEADING INDICATOR, and people’s bonuses are tied back to their closure rates.
So understanding how this can lead to some pencil-whipping, so verifying the CLOSURES of these CAPs plays a crucial role in the CHECK stage. Some companies will have a specific CHECK function for CAPs as a leading indicator. Others, and the way I always did it, will incorporate these CHECKS into the traditional audits and it works like this.
During a traditional audit, while we are out inspecting the physical workplace and while reviewing programs and their supporting documentation, we will take time to verify some CA’s have been implemented as stated in their CAP. This approach takes some planning. Weeks before the audit, we will ask the host to provide all of the CAPs closure records. We then will roll two dice (literally), and whatever the dice come up with will be the number we will use to select our samples. For example, we roll a 10; then, every 10th item will make it into our sample and be audited during the OSH/PSM audit. Some companies will segregate this approach based on the type of audit to be performed. Meaning that if the audit is a PSM/RMP audit, then only PSM/RMP-related CAs will be audited, or if the audit is a OSH audit, then only OSH-related CAs will be audited.
A mature SMS will have established a goal for these CHECKS, in both the number of CHECKS performed each year AND a % pass/fail of these CHECKS. Please do not be surprised or disheartened by what your first year of data tells you. It will most likely be UGLY, hence why these CHECKS are so crucial to our CAP process to reduce risks. If no one is manning the ship, the ship will run aground at some point! These CHECKS will become part of our leading indicators and REWARD system once we have a system in place to VERIFY/VALIDATE the metric.
This approach will also drive the organization to learn that CAPs need to become part of a “management system” fix so that the actions have some longevity. The #1 failure mode of these CHECKS is that the CA was put into place, but 2-3 months later, it is no longer in place, or it is no longer functioning as intended; thus, we are no longer getting any RISK REDUCTION from the CA. A year of these CHECKS will turn frustration amongst management into a revelation that CAPs need to be based in a “management system continuous improvement” effort and not just some simple actions taken to ensure we can close them out on time.
