A requirement that many think is “common sense” and “simple” continues to appear on 3rd party audit reports and OSHA/EPA citations year after year. So why is something so “common” and “simple” so difficult to comply with? Often times we make something simple to difficult for our own good. In this article I want to offer some suggestions on how we should be tracking our corrective actions to closure. But first, lets examine the PSM/RMP requirements for tracking “recommendations” from process safety activities:
1910.119(e)(5) The employer shall establish a system to promptly address the team’s findings and recommendations; assure that the recommendations are resolved in a timely manner and that the resolution is documented; document what actions are to be taken; complete actions as soon as possible; develop a written schedule of when these actions are to be completed; communicate the actions to operating, maintenance and other employees whose work assignments are in the process and who may
be affected by the recommendations or actions.
1910.119(j)(5) Equipment deficiencies. The employer shall correct deficiencies in equipment that are outside acceptable limits (defined by the process safety information in paragraph (d) of this section) before further use or in a safe and timely manner when necessary means are taken to assure safe operation.
1910.119(m)(5) The employer shall establish a system to promptly address and resolve the incident report findings and recommendations. Resolutions and corrective actions shall be documented.
1910.119(o)(4) The employer shall promptly determine and document an appropriate response to each of the findings of the compliance audit, and document that deficiencies have been corrected.
Officially it is recommendations from our Process Hazards Analysis, Incident Investigations, and 3-year Audits that have specific requirements that the actions be tracked to closure using a “system”. But reading between the lines, we also can deduct that recommendations or corrective actions from Mechanical Integrity inspections need to be tracked to closure. We often come across facilities that contract out these specialized mechanical integrity services and when the report arrives it is often shelved, never to be read again until an inspection/audit team arrives on site!
What does a true corrective action tracking system look like?
We start with well written recommendations! A recommendation must be written in a clear, concise, and “closable” manner. All too often, a recommendation is written in such a manner that it allows an uninformed management group to take the improper action(s), thus closing out a recommendation that will inevitably return in the future. The recommendation should be written in a manner that allows it to be understood 6-9 months after the event that generated the recommendation. It should also be written in a manner that forces management to implement actions that will correct the issues in a manner that will be a long-term fix and not some fly by night fix. We also have to encourage management to apply a recommendation “across the board”. By this I mean, if we find a fire extinguisher blocked by a trash can, it is too easy to think that is “the only fire extinguisher that will ever be blocked by a trash can”. So it is easy to send a supervisor out into the plant to “move the trash can”. He/she then sends an e-mail stating he/she “corrected the issue” and the recommendation is closed. But is it really? What did the facility do to ensure that exact same trash can will not find its way back in front of that same fire extinguisher? What about the other 300 fire extinguishers in the facility? Did the management group take action to ensure that none of the other fire extinguisher would be blocked by trash cans or any other movable objects? Also, in today’s corporate world with OSHA’s new twist on REPEAT CITATIONS; we need to even share our actions across business groups so that other facilities can reap the benefits of recommendations that are applicable to their business/facility. The days of closing out PSM/RMP recommendations at our facility and being done are long gone! It has become “a must” that we share our actions with those facilities with similar processes/hazards to ensure that the “company” is protected against REPEAT citations.
A true management system used to track recommendations will have some common traits.
First, each recommendation will be assigned to a member of management who is best suited to close the recommendation. Usually this would be the most senior level of management applicable to the action to be taken. This does not necessarily mean that the individual named will be doing 100% of the work, but rather they are 100% RESPONSIBLE for ensuring the recommendation is FULLY closed and ON TIME! If you have not yet been told by OSHA or EPA compliance officers, let me break the news to you… ALL PSM/RMP recommendations are to be assigned to management personnel who have the ability to assign resources (e.g. people, time, money, etc.). We all know that it is the front-line supervisors who carry out 99% of the actions, but it is the RESPONSIBILITY of management to see that the recommendations are closed on time.
Second, each recommendation will be assigned a due date so that its status can be tracked. Assigning a due date is a CRITICAL STEP, as each recommendation needs to be closed in a “timely manner”. Of course the term “timely manner” is a very subjective term, but management should push to ensure that all recommendations are closed as quickly as possible, realizing that some recommendations may require capital money to close and this may cause a delay while the request for funds is evaluated. But this delay is NOT a FREE TICKET! In other words, management may be forced to take immediate action(s) to lessen the risks, knowing that these actions are not the permanent fix. But the last thing we want to do is to identify a serious issue, determine actions necessary to address the issue, then sit around doing absolutely nothing until we have all our ducks in a row. (Please see my “Six Sigma Safety Process” articles in how I use the status of recommendations as a leading indicator). On another note, management needs to view these due dates as hard set dates! After all, it was management that set the dates; however, things change and management must respond to these changes. With that said, a true management system will have a FORMAL means to change recommendation due dates. I recommend that this should be your Management of Change (MOC) program, but some variation of such program could be used. Either way, I always had some RULES To PLAY BY when it came to changing due dates. The most important being, that I NEVER changed a date when a manager came to me requesting the change the day before it is due. To me, this is an indication that the manager was not “managing their recommendations” but rather “managing the due dates”. The next issue to deal with is the reason for the change. I tended to only grant changes that had legitimate reasons that were out of the control of the manager. For example, a piece of equipment is on back order and will be delayed for a couple of weeks. If the manager can show me the progression of the issue, meaning that he/she can show me when they originally placed the order and then when they received the back order notice, I then will grant an extension based on the anticipated arrival date of the equipment. PLEASE NOTE that doing MOC’s on personnel changes will help ensure that the new manager is presented with the recommendations that they have just adopted in their new role in a timely manner. Most of the time, this is a simple delete a name and replace the name on the recommendations, but there are times when the new manager may not have the skill set necessary to adequately oversee some of their newly adopted recommendations. When this occurs we may have to conduct a full review of the OPEN and PAST DUE recommendations to ensure they are assigned to the proper management team member.
Third, we do not want to make the tracking of these recommendations a “numbers game”, but one easy way to measure “management commitment” is to track the status of OPEN, CLOSED and PAST DUE recommendations. This process needs to be a FORMAL process where the plant/site manager is present with all managers who have OPEN or PAST DUE items. A status update is required for ALL PAST DUE items and items that have a due date within 10 business days of the meeting. This FORMAL meeting can either take place as part of regularly scheduled staff meetings or, as I like to do it, a separate meeting that is SOLELY FOCUSED on the recommendations. When the meeting is separate from the staff meeting, it should occur at least on a quarterly basis and sometimes it may need to be monthly, depending on how well the closure rates are looking. To provide management with a “measurable target” we need to set goals based on our recommendation closure rates. I have always liked to start with the following:
– at no time will there be more than 3% PAST DUE (keep in mind, managers can change dues dates using the system described above)
– ON-TIME CLOSURE rate will be 97%
Fourth, we must maintain the documentation of resolution for each recommendation. This means we will have a record of what was done, who did, and when they did it. We will keep this documentation for the LIFE OF THE PROCESS.