When you reach the end of your HAZCHEM investigation and have established the root causes of the incident, you’ll need to identify corrective actions that will prevent future system failures. You may also have compliance breaches that require direct action. This blog presents a three step method that uses a simple model to help you build a consistent, effective process for your own workplace.
NOTE: We recommend reading our blogs How to compile an ‘Incident Sequence’ in a HAZCHEM incident investigation and Establishing root cause after an incident involving hazardous chemicals as you work your way through this post.
Step 1: Recognise the limitations of the organisation
Before determining corrective actions you need to consider the limitations of your organisation and what can reasonably achieved using available resources. You’ll be looking at things like:
- Compliance: if you have any issues of non-compliance you’ll need to be clear about how your corrective actions will address (and resolve) every breach.
- Logistics: some corrective actions may require the installation of new machinery or renovate buildings and warehouses. You may be required to hire independent consultants and construction companies, or purchase machinery from overseas. If you’re operating in a regional or remote location would some of these options even be possible?
- Operational needs of the business: what if corrective actions interrupted business operations? How would you continue to generate revenue during a production shutdown?
- Workforce availability: How many projects can you effectively manage simultaneously? Even if you have an unlimited budget it’s unlikely you’ll have enough available managers and staff to implement a large number of projects at the same time.
REMEMBER: These considerations are to help you find the most practical and efficient means of addressing a system failure, not finding excuses for doing nothing.
Step 2: Apply the causation model
WORKPLACE EXAMPLE: An electrician was sent to investigate a lighting failure in the chemical store. As he walked toward the gas bottle cage another worker called out to warn him about a gas bottle trolley that had been left in front of the cage overnight. The electrician kept walking while turning back to respond to his co-worker, but collided with the trolley and knocked a cylinder of acetylene to the ground. The cylinder was not properly restrained and become a flying projectile after colliding with the floor. The electrician was seriously injured.
If you’ve read our previous blog Establishing root cause after an incident involving hazardous chemicals we applied a simple causation model to that incident and identified a number of causal factors including a faulty safety strap on the gas bottle trolley. Let’s take a look at how we will apply the causation model when determining the most effective corrective actions.
Understanding the causation model
Our causation model prompts you to look for corrective actions that address five different areas of the organisation as follows:
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1. |
TASK |
Corrective actions that address system failures and compliance issues in the TASK group will focus on reviewing work methods and updating operating procedures. |
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2. |
MATERIAL |
When developing corrective actions in the MATERIAL group, you’ll be doing things like repairing or replacing machinery, using different chemicals, installing new chemical stores, putting up warning signs and placards, updating PPE. |
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3. |
ENVIRONMENT |
Corrective actions in the ENVIRONMENT group change physical conditions by introducing mechanical ventilation systems, or tightening up housekeeping practices, or moving a chemical store outside. |
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4. |
PERSONNEL |
The PERSONNEL group is all about your workers. Corrective actions here include providing better supervision, conducting training sessions, and changing rosters. |
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5. |
MANAGEMENT |
Introducing a risk management plan, scheduling preventive maintenance, and issuing written procedures are all corrective actions that address failures in MANAGEMENT. |
Using the causation model
Let’s imagine now you are wanting to introduce corrective actions to address the acetylene cylinder not being properly strapped to the gas bottle trolley. Apart from being unsafe, this is a breach of AS4332-2004 - The storage and handling of gases in cylinders. Using the causation model you can evaluate the effectiveness of corrective actions in each of the five areas.
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1. |
TASK |
Review the work procedure for fitting a gas cylinder to the trolley and introduce a system of cross-checks to ensure the cylinder is properly secured. |
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2. |
MATERIAL |
Replace the safety straps on the gas bottle trolley and ensure the trolley is kept in working order. |
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3. |
ENVIRONMENT |
Improve housekeeping procedures so that gas cylinders are not left on trolleys overnight, but put away correctly in the gas bottle cage. |
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4. |
PERSONNEL |
Train individual staff so they know the correct procedure for securing a cylinder to the gas bottle trolley. Providing additional hazard awareness training so they understand the volatility of acetylene gas and understand their responsibilities under AS4332-2004 - The storage and handling of gases in cylinders, and why the cylinders cannot be allowed to fall. |
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5. |
MANAGEMENT |
Introduce scheduled maintenance that extends to gas bottle trolleys. Implement a procedure for supervisors to mark off a daily inspection of the chemical stores (with periodic checks that gas bottles are correctly restrained). If cylinders are left unattended on trolleys, have supervisors enforce with disciplinary action. |
One of the benefits of using this causation model is it addresses the same corrective action from five different angles and helps you implement change more effectively. For example: to ensure that gas bottles are correctly secured to safety straps:
- Trolleys need to be repaired (MATERIAL)
- The actual TASK needs reviewing
- MANAGEMENT need to issue and enforce a new procedure
- The overall state of housekeeping (ENVIRONMENT) needs to be improved
- Workers (PERSONNEL) need to be trained and supervised
Step 3: Create a priority list
Once you have identified corrective actions that address every system failure and causal factor, you need to make a priority list to include in your report. Even if your organisation is very big it is unlikely you will enough time and resources to implement all of your recommendations straight away.
- When creating your priority list you might want to return to Step 1 and review each of the considerations which could affect your ability to implement a corrective action. You may want to include a number of different possibilities in your final report.
Next steps
Developing corrective actions happens at the end of an incident investigation. For a holistic understanding of the investigation process why not download our free eBook Key steps in a HAZCHEM incident investigation. We use real world examples to demonstrate how an incident investigation unfolds from the time of the incident through to issuing the final report. Download and read it today by clicking on the image below.
