After a failed attempt, reviewers first control any immediate hazard, then establish what happened, compare actual work with the written procedure, and decide what should change. Corrective actions need an owner, a deadline, appropriate approval, and follow-up to confirm completion and effectiveness. The exact rules depend on the field and jurisdiction; the examples below draw on NASA mishap requirements and U.S. OSHA workplace guidance, not a universal protocol for every kind of failed procedure.
1. Stabilize the situation before investigating
If continuing the work could endanger people, damage assets, or compound the failure, stop or isolate the affected activity using the applicable emergency and operating rules. Containment is not a substitute for the investigation; it prevents the situation from worsening while facts are gathered. Neither NASA nor OSHA prescribes one containment measure for every hazard, so the response must fit the site and the risk.
NASA’s mishap procedure allows an investigating authority to recommend immediate corrective action to protect safety in ongoing operations. OSHA’s program-evaluation guidance likewise recommends promptly correcting identified safety-program problems and preventing recurrence. NASA NPR 8621.1D, Chapter 6 and OSHA’s Safety Management: Program Evaluation and Improvement describe these responsibilities in their respective contexts.
2. Reconstruct what happened from evidence
Build a factual timeline before assigning blame or changing the procedure. Compare what the written instructions called for with what the person or system actually did, the conditions at the time, the expected result, and the point where events diverged. Preserve relevant records and other evidence under the organization’s applicable process.
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OSHA’s process-safety audit guidance describes reviewing relevant documentation, inspecting actual conditions, interviewing personnel, and comparing written programs with work as performed. That approach can reveal whether the issue involved a missing or unclear instruction, outdated equipment or process assumptions, training, execution, or a missing control. It does not establish the cause of any particular failure; conclusions should be limited to what the evidence supports. OSHA 29 CFR 1910.119 Appendix C is nonmandatory guidance for process-safety management.
3. Identify what needs to change
Use the findings to assess whether a procedure step is absent, ambiguous, outdated, impractical, inconsistent with current conditions, or poorly communicated. Also consider whether training, supervision, tools, process design, maintenance, or management controls contributed. The failed attempt alone does not prove that the procedure—or the person following it—was the cause.
OSHA notes that a finding might call for a simple procedure change or minor maintenance, while another may require engineering work or a deeper review of procedures and actual practices. Its guidance also says to document why no action is taken when a finding does not lead to a change.
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Assess the effects of any proposed procedure change rather than treating it as an isolated edit. OSHA explains that process changes may require changes to operating procedures and practices, that consequences should be evaluated and communicated, and that management-of-change procedures should be used as appropriate—even when a change appears minor. OSHA’s process-safety guidance addresses those considerations.
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4. Compare proposed corrective actions
When more than one action could address a finding, compare them against the evidence and the work’s risks. A useful decision framework is:
- Finding: Does the action address a documented finding or evidenced cause?
- Risk reduction: How likely is it to reduce the risk or prevent recurrence?
- Feasibility: What resources, time, and expertise will implementation require?
- Side effects: Could the change introduce a new hazard or disrupt another control?
- Verification: How will reviewers confirm both implementation and effectiveness?
This framework synthesizes NASA and OSHA guidance on linking actions to findings, prioritizing and resourcing work, managing procedure changes, and checking implementation. It is a practical comparison method, not a quoted standard.
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5. Assign responsibility and obtain review
Each chosen action should be connected to the finding it addresses, assigned to a responsible person or organization, and given a completion date. Review it through the authority appropriate to the organization and the risk; consult safety, technical, quality, maintenance, or other relevant specialists when needed.
NASA’s mishap corrective-action process
For NASA cases covered by NPR 8621.1D, the corrective action plan (CAP) addresses actions for recommendations approved by the appointing official. The plan identifies each action and its estimated completion date, the lowest-level responsible NASA organization, and a matrix or other link between actions and findings or recommendations. The appointing official may consult safety and other appropriate offices, accepts or rejects the plan, and returns a rejected plan with comments for revision. NASA specifies submission within 15 workdays after the CAP is tasked. These are NASA-specific requirements, not general deadlines.
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OSHA’s process-safety audit guidance
OSHA’s nonmandatory process-safety guidance describes management review of audit findings to determine appropriate actions, priorities, timeframes, resources, and responsibilities. It calls for documenting the action and responsible person or team, and recording the reason when no action is selected.
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6. Track implementation and verify results
Track each action through completion and retain a record of its status. Verify that the action was implemented as approved, then assess whether the underlying deficiency was addressed and the control works as intended. An action marked “complete” is not, by itself, evidence that recurrence risk has been reduced.
For NASA cases covered by its procedure, managers implement and track corrective actions, report status at intervals set by the appointing official, and update the safety office at least every 30 workdays until the plan closes. The NASA safety office tracks adherence to the plan and verifies implementation, completion, and closure. OSHA recommends tracking systems, status reporting, and a final implementation report; its broader program guidance also recommends evaluating whether the program works as intended and whether actions prevent recurrence. The NASA interval is specific to that process and should not be treated as a general workplace deadline. NASA NPR 8621.1D, Chapter 6; OSHA 29 CFR 1910.119 Appendix C; OSHA program-evaluation guidance.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.7. Close the review and share relevant lessons
Close the review under the applicable process only after assigned actions are completed and their status is documented. NASA’s procedure describes safety-office verification, closure statements for specified higher-severity and high-visibility cases, and a completion statement recording investigation, corrective-action closeout, and lessons learned as applicable. It also sets requirements for retaining and handling investigation records.
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For applicable NASA cases, the procedure calls for lessons learned to include the public-release-authorized executive summary, findings, and recommendations, and to be submitted within ten workdays of assignment. NASA’s Lessons Learned system collects official, reviewed lessons from its programs and projects; the ten-workday requirement belongs to the NASA process and case types described in the procedure, not to every organization.
Who should take part in the review?
Choose reviewers who understand both the procedure and the work. Include affected workers where practical, and add safety, technical, quality, maintenance, or human-factors expertise when the failure warrants it. OSHA recommends trained, impartial audit leadership and team members familiar with the process and audit methods; the team’s size and mix of disciplines should reflect process complexity. Its program-evaluation guidance also calls for worker participation in evaluating programs and identifying improvements.
When human performance is relevant to a NASA investigation, the active NASA Human Factors Analysis and Classification System handbook provides guidance on gathering, coding, trending, and tracking human-factors data. It is guidance, not a replacement for the site’s required investigation method. The NASA technical-standards record lists the handbook document date as July 31, 2023. NASA-HDBK-8709.25, Human Factors Handbook Procedural Guidance and Tools.
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