
The Problem
The investigation was solid. The logic tree held up. The team identified a real cause — not just a symptom — and documented it cleanly.
Then the corrective action was: “Remind operators to follow procedure.”
This is the corrective action quality gap. It’s the moment where rigorous analysis collapses into a weak response, and the organization quietly accepts that the failure will return. Nobody flags it. The RCA gets closed. The risk stays in the system.
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