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After a failed attempt, reviewers first control any immediate hazard, then establish what happened from evidence, compare actual work with the written procedure, and decide what must change. Corrective actions should be tied to findings, assigned owners and deadlines, reviewed by the appropriate authority, tracked to completion, and checked for effectiveness before the review closes. The exact legal process depends on the industry and jurisdiction; the examples below draw on NASA mishap requirements and U.S. OSHA guidance, not a universal protocol for every kind of work.
1. Stabilize the situation before investigating
If continuing the work could put people or assets at risk or make the failure worse, stop, isolate, or otherwise control the affected operation under the applicable emergency and operating rules. Containment should fit the hazard and local procedure; neither NASA nor OSHA specifies one measure for every failure. NASA’s mishap procedure allows an investigating authority to recommend immediate corrective action to protect ongoing operations, while OSHA guidance recommends prompt correction of identified safety-program problems and prevention of recurrence.
NASA NPR 8621.1D, Chapter 6 applies to NASA’s covered mishap process. OSHA’s process-safety audit appendix is guidance rather than a mandatory protocol.
2. Reconstruct what happened from evidence
Build a factual sequence: what the procedure instructed, what the person or system did, what conditions existed, what result was expected, and where actual events diverged. Preserve relevant records and evidence. In its process-safety audit guidance, OSHA identifies documentation review, inspection of actual conditions, interviews with personnel, and comparison of written programs with real practice as useful parts of an audit.
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This comparison helps determine whether the procedure was unclear or incomplete, whether equipment or process conditions had changed, whether training or controls were inadequate, or whether execution differed from the documented steps. A failed attempt alone does not establish operator error or any other cause; findings should stay within what the evidence supports.
3. Decide what needs to change
Reviewers should check whether a procedure step is missing, ambiguous, outdated, impractical, inconsistent with current equipment or conditions, or poorly communicated. They should also consider whether training, supervision, process design, tools, or management controls contributed. OSHA notes that findings can call for anything from a procedure change or minor maintenance to engineering work or a deeper review of actual practices. If the organization decides not to act on a finding, its rationale should be documented.
Procedure edits can affect risk elsewhere. OSHA advises evaluating and communicating the consequences of procedure changes and using management-of-change processes as appropriate, even when a change seems minor.
4. Compare and approve corrective actions
More than one response may address a finding. Compare options based on how directly they address an evidenced cause, their expected effect on risk and recurrence, feasibility and resources, completion time, side effects or new hazards, and how implementation and effectiveness will be verified. These are practical comparison criteria synthesized from NASA and OSHA guidance, not a quoted standard.
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In NASA’s covered mishap process, a corrective action plan (CAP) links each action to findings or recommendations, names the responsible NASA organization at the lowest appropriate level, and gives an estimated completion date. The appointing official may consult safety and other relevant offices, accepts or rejects the plan, and returns a rejected plan with comments for revision. NASA’s chapter sets a 15-workday deadline for submitting a CAP after it is tasked; that deadline belongs to this NASA process, not to every workplace.
OSHA’s nonmandatory process-safety audit guidance similarly describes management review to set appropriate actions, priorities, timeframes, resources, and responsibilities. Where no action is selected, document why.
5. Assign, track, and verify actions
Each corrective action needs a responsible owner, a completion target, and a way to report progress. NASA requires managers in its covered process to implement and track actions, report at intervals set by the appointing official, and update the safety office at least every 30 workdays until the plan closes. Its safety office tracks whether actions follow the plan and verifies implementation, completion, and closure. These intervals are NASA-specific requirements.
OSHA recommends a tracking system, status reporting, and a final implementation report to support closure and show that deficiencies were addressed. Its broader safety-program guidance also recommends checking that corrective actions are completed on time and that the program works as intended, including whether changes help prevent recurrence.
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Close the review under the applicable process only after required actions are complete and their status is documented. NASA’s chapter describes safety-office verification, closure statements for specified higher-severity and high-visibility cases, and a completion statement recording the 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 chapter calls for lessons learned to include the public-release-authorized executive summary, findings, and recommendations, with submission within ten workdays of assignment. NASA’s Lessons Learned system collects official, reviewed lessons from NASA programs and projects. The ten-workday deadline is specific to the NASA cases covered by its procedure.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.Who should review a failed attempt?
Choose reviewers who understand the work and procedure, and involve affected workers where practical. Add technical, safety, quality, maintenance, or human-factors expertise when the failure requires it. OSHA recommends trained, impartial audit leadership and team members familiar with the process and audit methods; the team’s size and disciplines should reflect process complexity. OSHA also emphasizes worker participation in program evaluation and improvement.
Where human performance is relevant, NASA’s active Human Factors Handbook Procedural Guidance and Tools (NASA-HDBK-8709.25), dated July 31, 2023, provides guidance on gathering, coding, trending, and tracking human-factors data. It does not replace the investigation method required at a particular site.
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How the examples apply outside NASA and process safety
The review sequence—contain risk, establish facts, compare practice with the procedure, assign and verify corrective actions—is useful as a general framework. The specific NASA deadlines and approval roles apply to NASA’s covered mishap process. OSHA’s cited process-safety audit appendix is explicitly nonmandatory guidance for process-safety settings, and OSHA’s general program-evaluation guidance is U.S. workplace guidance. Other sectors, organizations, and jurisdictions may have different reporting, investigation, approval, and record-retention requirements.
Sources: NASA NPR 8621.1D, Chapter 6 (effective July 6, 2020; listed expiration December 30, 2028); OSHA 29 CFR 1910.119 Appendix C (nonmandatory process-safety guidance); OSHA Safety Management: Program Evaluation and Improvement (accessed October 3, 2026); NASA Lessons Learned (last updated July 26, 2023); and NASA-HDBK-8709.25.
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