122: Procedure Issue

Node Procedure Issue

Definition/Typical Issues

This major root cause category addresses issues related to all aspects of procedures, including:

  • Failure to use the correct procedure
  • Failure to use the correct procedure correctly
  • Errors and omissions in the procedures

Did personnel fail to use a procedure for the task? Was the procedure incorrect or incomplete? Was no procedure developed for the job, even though a procedure was required to perform the job?

Note 1: Procedures provide detailed step-by-step directions on how to accomplish a task. Guidance documents that provide general guidance and principles should be addressed under the Company Standards, Policies and Administrative Controls (SPAC) Issue (#225) or Standards, Policies and Administrative Controls (SPAC) Not Used (#230) nodes.

Examples

Example 1

  • An operator failed to complete a critical step in an operation because the procedure he obtained from the procedure files was not the most recent revision.

Example 2

  • A new operator failed to complete a critical step because the procedure was not detailed enough; it was written as a guideline/reminder for experienced operators.

Typical Recommendations

  • Ensure that copies of procedures are available for worker use at all times.
  • Ensure that procedures are in a standard, easy-to-read format.
  • Perform a walkthrough of new and revised procedures.
  • Use look-up tables instead of requiring calculations to be performed.
  • Develop a written policy describing the management system for the procedures management system that describes the process for creating, updating, and maintaining operating procedures.
  • Address specific roles and responsibilities in the written policy describing the management system for the procedures management system.

Cross-References

Version 10 Element(s)
Node ID Node Name
111 Procedures

 

PSM Element(s)
14

 

RBPS Element(s)
Operating Procedures
Safe Work Practices

 

Maritime Element(s)
Node ID Node Name
120 Procedures
80 No/Inadequate Safe Work Practices
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