Why Our Corrective Actions Fail

by Kevin McManus, Chief Excellence Officer, Great Systems

Tens of thousands of corrective and preventive actions cross my eyes and pass through my ears as time passes. Over time, I began to see a definite pattern. It wasn’t the obvious ‘most of our fixes are weak’ pattern many people see at work. You know what the weak fixes are – retraining, procedure expanding, and punishment-focused fixes. Instead, it was a pattern of a less visible nature. I saw a pattern of psychology that helps explain why our corrective actions fail.

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What is the Psychology Behind Our Corrective Action Failures?

In a nutshell, here is what I saw. When a person writes a corrective action to directly address a human error, the tendency is to recommend a relatively weak fix. For example, suppose we want to write a corrective action to address a problem where people don’t wear the right work gloves. What do we often recommend? Most responses focus on glove availability and the use of rule reminders. How effective are those fixes? What is the probability that the behavior happens again?

Instead, if we use a work systems gap or weakness as our initial corrective action reference point, we are more likely to recommend a systematic fix. Suppose we hand out gloves as part of job preparation each day. Does this increase the chance that people wear them consistently the remainder of the day? What if supervisors routinely measure and share the relative degree that personal protective equipment use consistently occurs? Does this increase the likelihood of glove wear?

How does the daily work system reinforce effective glove use?

DISCOVER MORE: How to Measure and Improve Your Process Improvement Work System

What % of Corrective Actions Should be Process Improvements?

This is a fun question. The tendency is to say that all corrective actions should be process improvements. Currently, most are far from that. Reminders and discipline do not change the process – how work is done. The same can be said for the also popular ‘re-training’ fixes. These types of change simply ask people to act differently and hope that they do. What percentage of the corrective actions you write are true process refinements?

Others point out that corrective actions are more temporary in nature. They feel that corrective actions can be relatively weak as long as the preventive actions are effective. This may be true, but does this approach result in a certain amount of redundant effort? As a goal, strive to have all fixes be of a process improvement nature. The job is done differently. One or more steps in the procedure are modified.

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Why Our Corrective Actions Fail – Weak versus Strong Fix

Too many organizations rely on failing fixes such as reminders, discipline, and retraining. What is the case in your company? Our over-reliance on weak fixes is partially driven by our choice of root cause analysis approach. Traditional approaches, such as the 5 Why technique or fishbone analysis, accept human error as a root cause. Experience shows me that this is not a best practice to follow. Viewing human error as a root cause is a process error in its own right. Instead, use a root cause analysis approach that looks for the systemic reasons behind those persistent human errors that exist.

All people make mistakes. Do you want to produce mistake-free work? If so, design your work systems so they discourage, versus encourage, human error. As an example, our space programs and nuclear power generation companies get this. They rely heavily on safeguards such as well-designed checklists and effective job preparation to help people consistently do their jobs well.  They don’t rely primarily, if not solely, on memory as an mistake prevention tool. What percentage of the time do you count on memory to help minimize errors? Is it possible that the use of more effective safeguards could significantly improve performance?

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Match Your Fix Expectations to the Problem’s Potential Severity

The trend on proactive process improvement is to address the potential, versus the actual, severity of a problem. Such a practice results in a more in-depth investigation. When we focus only on the actual issue, we tend to focus only on the people closest to that problem. Instead, match your fix expectations to a problem’s potential severity.

For example, suppose you experience a ‘near miss’ fatality. If you do, don’t ‘just’ shut down and conduct a site-wide safety stand down. Instead, expect at least one engineered fix (hazard removal / minimization) in your corrective action mix. As a rule, limit the number of weak fixes you accept. Human factors improvements, target guarding, and hazard mitigation offer the best solutions.

What are Your Favorite Fixes?

The changes I recommend here may sound simple. Before you toss my observations aside, take a look at the last fifty or so corrective actions you have written or reviewed. What patterns exist? What are your favorite fixes? How relatively strong, or weak, are they? Where do your fixes tend to fall on the hierarchy of controls? What percent of the time do you focus on trying to change people, instead of trying to change systems?

Better fixes exist. For example, use the hierarchy of controls to help you write better corrective actions. With each fix you write, focus first on the top half of the hierarchy. What type of changes can you think of a human factors nature? How can we better guard the target? Can we somehow make changes that help minimize the hazard itself?

EXPLORE MORE: Workplace Safety Best Practices

Don’t Accept Human Error as a Root Cause

For years, I made the mistake of seeing human error as a root cause. Then, I started teaching the TapRooT® root cause analysis approach as a contract trainer. The design of this approach forces the user to look for the systemic causes of human error. In other words, human error is rarely, if ever, a root cause with this process. What percentage of your root causes are human errors? Is it possible that a different root causes analysis approach could lead you to better, work system focused fixes?

If we continue to try to write corrective and preventive actions to address human error directly, we will continue to write relatively weak fixes. It’s a key reason our corrective actions fail. As a start, make the choice to reject human error as a root cause. Instead, always search for the systemic reasons humans do things they themselves really don’t intend to do. How often do your fixes fail? Is it possible that a root cause analysis process shift, along with a psychological shift, could lead you towards a more mistake free workplace?

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Keep improving!

Kevin McManus, Chief Excellence Officer, Great Systems

Please email me your questions at kevin@greatsystems.com

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NOTE: if you found value in this article, you might also benefit from reading my new book “Error Proof- How to Stop Daily Goofs for Good”, which is now for sale on Amazon.com.