123: Correct Procedure Not Used
Definition/Typical Issues
Was there a procedure for the task? Was a procedure used to perform the job? Was a copy of the procedure available to the worker? Was it difficult to obtain the procedure? Did the procedure system require that the procedure be used as a task reference or was it just for training? Were personnel required to take copies of the procedures to the field? Should the use of the procedure be required even though it was not in the past? Was the procedure written in a language that was familiar to the worker? Was the use of the procedure discouraged?
Examples
Example 1
- An operator made a valving error. He performed the task without using the controlled procedure because he would have had to make a copy of the master.
Example 2
- A mechanic incorrectly performed a repair job on an important pump without using the procedure. Mechanics were not required to use the procedure in the field because it was for training purposes only. However, using the procedure in the field would probably have prevented the error made by the mechanic.
Typical Recommendations
- Ensure that copies of procedures are available for worker use at all times.
- Develop procedures with sufficient detail for the least experienced, but qualified worker.
- Supplement training and reference materials with easy-to-carry checklists.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 112 | Not Used |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 121 | Not Used |