Perform Independent Effectiveness Reviews of Corrective Actions Assigned as a Result of Previous Accident Investigations
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Type:  Lessons Learned

Publisher:  U. S. Department of Energy, Office of Fossil Energy

Published As:  Public

Date: 

Topics:  Operations, Performance Measurement, Management Systems, Quality Assurance, Oversight

An Strategic Petroleum Reserve accident investigation of a serious injury that occurred during a tank repair project found that many of the Judgments of Need were the same as those recommended following the investigation of two separate SPR fatalities only two years prior. After each fatality, corrective actions had been developed and supposedly fully implemented in order to prevent recurrence. The status of each of these corrective actions had been recorded as "closed," yet accidents - and a fatality - had occurred again.

Some of the same deficiencies that had contributed to two worker fatalities were once again found to be present, despite having been reported as corrected less than two years before. This sobering realization continues to challenge SPR management to provide more effective and sustainable controls.

Lessons Learned: Independent corrective action effectiveness reviews must be conducted of all corrective actions from previous accident/incident reports to measure their current effectiveness regarding oversight, training, stop work, and lessons learned.

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