This brings us to the final installment of our risk management newsletter series on the risk management process. In the last three articles, we addressed risk assessments, risk controls and implementing solutions. You can find those articles in our previous newsletters located on the SDAO Resource Library accessible from our website. In this article, we will focus on the equally important topic of following up.

This topic brings me back to my former career in manufacturing and a memory I will not soon forget. In short, we had a fire in one of the tools on the factory floor after preventative maintenance was performed. We went through our investigation and followed the risk management process. It was determined that during maintenance a bolt was left in the tool that caused an electrical short and the resulting fire. We decided to mitigate the risk of additional fires by implementing a plan. One portion of the plan was that all tools and parts must be put into a plastic bin while performing maintenance. This would ensure that no tools or parts were left in the tool after maintaining the equipment.  

Not even a year after that initial fire, we had another fire in the same tool. This fire was caused by unintended consequences of the plan we put in place. This time, the plastic bin we required them to put tools and parts in was left in the tool and caused the fire.  

Shockingly, interviews after the fire revealed that workers were aware that bins had been left in the tool on several occurrences and only discovered during preventative maintenance. Unfortunately, they never reported these occurrences. Of course, this led to the second fire. 

Now 20 years later and a little bit wiser, I can see several red flags in this event, but for the case of this article we will stay on topic. We did not have a plan to follow up. If we had implemented a follow up process and talked with staff operating the tool and performing the maintenance, we would have identified soon after the initial fire that our plan was not good enough to mitigate the risk. 

My hope is that by sharing this experience with you, you will learn from the costly lessons that I learned the hard way. You see, when we evacuated the factory due to the fire, the company lost over a million dollars a minute in lost productivity. The risk management process should be looked at as a continual process, and we should always be following up when we make changes to the workplace and work processes. So, let’s talk about the considerations of the follow-up process.  

Taking into consideration the previous steps of the risk management process, we should have identified the solutions to be implemented and the intended outcomes of those solutions. Once those solutions get implemented, we want to have a formal process in place to follow up on those changes to the work environment and processes.

This follow up should include: 

• Assign an individual or team to conduct the follow up, 
• Identify the time frame(s) for the follow up to occur, and  
• Set the expectation of affected staff to report back any issues with the implemented changes as they are identified.  
  Through the follow-up process, we are trying to identify any unintended consequences of the plan that was implemented and decide if our plan meets the intended outcomes. If any deficiencies are found, we should be working back through the risk management process to fine tune the plan so that the intended outcomes are reached. So, you might be asking what the actual follow up looks like… I’m glad you asked. It could look very different depending on the complexity of the plan put in place, but below are some common practices:
   
• Interviewing (talking with) affected employees 
• Auditing processes and procedures 
• Observing the work process and workflow 
• Measuring results 
• Addressing near misses and unintended consequences by working back through the risk management process 

We hope you have enjoyed our news article series on the risk management process and hope you have been able to glean some helpful tactics and practices to implement in your organization. As always, your risk management team is here as a resource for you and your district. Please reach out to us at riskmanagement@sdao.com if we can be of service to you in helping mitigate risk and prevent losses.