Environmental Engineering Reference
In-Depth Information
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Phase.III:.Corrective.actions
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Phase.IV:.Inform
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Phase.V:.Follow-up
The.objective.of.investigating.and.reporting.the.cause.of.occurrences.is.to.enable.
the. identiication. of. corrective. actions. adequate. to. prevent. recurrence. and. thereby.
protect. the. health. and. safety. of. the. public,. the. workers,. and. the. environment..
Programs.can.then.be.improved.and.managed.more.eficiently.and.safely.
The. investigation. process. is. used. to. gain. an. understanding. of. the. occurrence,.
its. causes,. and. what. corrective. actions. are. necessary. to. prevent. recurrence.. The.
line.of.reasoning.in.the.investigation.process.is.(1).outline.what.happened.step.by.
step;.(2) begin.with.the.occurrence.and.identify.the.problem.(condition,.situation,.or.
action.that.was.not.wanted.and.not.planned);.(3).determine.what.program.element.
was.supposed.to.have.prevented.this.occurrence.(was.it.lacking.or.did.it.fail?);.and.
(4) investigate.the.reasons.why.this.situation.was.permitted.to.exist.
This. line. of. reasoning. will. explain. why. the. occurrence. was. not. prevented. and.
what.corrective.actions.will.be.most.effective..This.reasoning.should.be.kept.in.mind.
during. the. entire. root. cause. process.. Effective. corrective-action. programs. include.
the.following:
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Management.emphasis.on.the.identiication.and.correction.of.problems.that.
can.affect.human.and.equipment.performance,.including.assigning.qualiied.
personnel.to.effectively.evaluate.equipment.and.human.performance.prob-
lems,.implementing.corrective.actions,.and.following.up.to.verify.corrective.
actions.are.effective
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Developments.of.administrative.procedures.that.describe.the.process,.iden-
tify.resources,.and.assign.responsibility
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Development. of. a. working. environment. that. requires. accountability. for.
correction. of. impediments. to. error-free. task. performance. and. reliable.
equipment.performance
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Development.of.a.working.environment.that.encourages.voluntary.reporting.
of.deiciencies,.errors,.and.omissions
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Training.programs.for.individuals.found.at.fault.in.root.cause.analysis
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Training.of.personnel.and.managers.to.recognize.and.report.occurrences,.
including.early.identiication.of.signiicant.and.generic.problems
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Development. of. programs. to. ensure. prompt. investigation. following. an.
occurrence.or.identiication.of.declining.trends.in.performance.to.determine.
root.causes.and.corrective.actions
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Adoption. of. a. classiication. and. trending. mechanism. that. identiies. those.
factors.which.continue.to.cause.problems.with.generic.implications
A.description.of.each.of.the.ive.phases.is.provided.to.clarify.the.purpose.of.each.
phase.of.the.root.cause.analysis.
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