Blog » Corrective and preventative action plan example

Corrective and preventative action plan

Corrective and preventative action (CAPA) plans are essential in a company’s Safety and Health Program. CAPA plans should comprise three main components; hazard prevention and control, education and training, and program evaluation and implementation.

Plans for CAPA should always include a focus on worker involvement, as workers often have the best understanding of the conditions that create hazards and insights into how they can be controlled. Involved workers are more likely to report unsafe conditions that can cause potential injuries.

Awareness of these reported hazards allows an opportunity to control them before anyone gets hurt. Providing education and training gives a greater understanding of hazards and controls, which aids in developing and implementing the plan by employees. Monitoring and evaluating the plan over time can give markers on its progress to track performance and possibly make improvements.

Procedures for implementing a CAPA plan in a facility will most likely look different for every facility depending on its hazards and needs. Performing an initial evaluation of the facility’s hazards and identifying actions taken to control them is beneficial in determining what should be done to improve the CAPA plan.

CAPA plan example

An example of a success story relating to CAPA plans can be seen from the improvements made at KIC Chemicals, Inc., from 2012 onwards. This example illustrates the critical aspects of a CAPA plan and shows the benefits obtained over time.

The state consulting agency New York Division of Safety and Health (NYS DOSH) and OSHA’s On-Site Consultation Program provided an initial consultation to KIC Chemicals to establish and improve the effectiveness of their safety and health program. In 2012, during the first on-site consultation visit walkthrough, NYS DOSH consultants identified the following hazards:

• open-sided floor or platforms that were not guarded
• unlabeled containers of chemicals
• improper storage of flammable liquids
• missing exit signs
• lack of a personal protective equipment assessment

CAPA implementation

In addition to identifying and assisting with hazard abatement, the consultation service assisted the employer in developing an adequate safety and health management system, establishing training programs, a weekly and monthly inspection program, a safety committee consisting of five employees, and instituting a ‘safety first’ culture among employees.

After working with the On-Site Consultation Program for a year, KIC Chemicals established an effective safety and health management system. This resulted in the companies’ Total Recordable Case (TRC) rate remaining at zero for 2012, 2013, 2014, 2017, and 2018 (this success story was recorded in 2019).

The first aspect of this story relating to CAPA is the identification and immediate abatement of hazards. Identifying control options for hazards, selecting and implementing controls, creating and updating hazard control plans, and checking to ensure that controls are effective are essential in mitigating hazards and preventing incidents.

Correcting the initial hazard is crucial, but it is also essential to follow up to verify that control measures remain effective. Employers should track progress in implementing controls, inspect and evaluate controls once they are installed, follow routine preventative maintenance practices, and confirm that work practices, administrative controls, and PPE use policies are being followed.

The weekly and monthly inspection program at KIC Chemicals is a great example of how hazard control can be taken a step further to make sure controls are adequate and working correctly.

The next CAPA-related aspect of this story has to do with the training programs KIC Chemicals provided to employees after their consulting walkthrough. Education and training provided employers, managers, supervisors, and workers with the knowledge and skills needed to do their work safely and avoid creating hazards that could place themselves or others at risk.

The training increased employee awareness and understanding of workplace hazards and how to identify, report, and control them. Training on safety and health program awareness and additional specialized training (if work involves unique hazards) can effectively convey safety concepts, ensure understanding of hazards and their controls, and promote good work practices.

It is important to note that when workers understand their specific roles within the safety and health program and how they should carry out those responsibilities, they can participate in incident investigations and program evaluation and improvement. KIC Chemicals developed a training plan for their employees to better participate in the newly updated safety and health plan. Continuous training led to incident prevention.

Program evaluation and improvement is the last CAPA aspect involved in KIC Chemicals’ safety and health program. Once a safety and health program is established, it should be evaluated initially to verify that it is being implemented as intended. Employers should periodically and at least annually assess what is working and what is not and whether the program is on track to achieve its goals.

CAPA program evaluation

Program evaluation and improvement can include:

• establishing, reporting, and tracking goals and targets that indicate whether the program is making progress
• evaluating the program initially and periodically after that, to identify shortcomings and opportunities for improvement
• providing ways for workers to participate in program evaluation and improvement

Some ways that performance and progress monitoring can be accomplished are by tracking both lagging and leading indicators. Lagging indicators are used to track worker exposures and injuries that have already occurred. Examples are the total number of injuries and illnesses, results of worker exposure monitoring that show that exposures are hazardous, and worker’s compensation data.

Leading indicators are used to track how well various aspects of the program have been implemented and reflect steps taken to prevent injuries or illnesses before they occur. Examples of leading indicators include the number of employees involved in program activities, number of employee safety suggestions, number of workers who have completed required safety and health training, and the number of hazards identified during inspections.

KIC Chemicals’ implementation of leading indicators such as the inspection programs and a safety committee contributed to the decrease in lagging indicators shown in their TRC rate.

Conclusion

Whenever these assessments identify opportunities to improve the program, employers, managers, and supervisors—in coordination with workers—should make adjustments and monitor how well the program performs. Sharing the results of monitoring and evaluation within the workplace, and celebrating successes, will help drive further improvement.