125: Procedure Difficult to Obtain
Definition/Typical Issues
Was the procedure difficult to access? Were no copies of the procedure available in the designated file, shelf, or rack? Was the "master copy" of the procedure not available for reproduction? Were the copies of the procedures located remotely from where the work is performed? Was procedure use inconvenient because of working conditions (e.g., tight quarters, weather, protective clothing)?
Examples
Example 1
- An operator made a valving error that resulted in an overflow. He did not use the controlled procedure because it would have required him to make a copy of the master. Instead he used the procedure copy he had at his workstation. This procedure was out of date.
Example 2
- An electrician was troubleshooting a large breaker. After determining what the problem was, she should have obtained a copy of the procedure for replacement of the charging springs. But that would have required her to return to the maintenance shop. So she replaced the spring based on memory. As a result, a plant startup was delayed when the breaker failed to close.
Typical Recommendations
- Place copies of operations and maintenance procedures in the appropriate work areas so that the procedures are always available for personnel to use.
- Maintain master copies of all procedures and control access to these masters.
- Make procedures available to operators at all times.
- Provide backup power supplies to computers and printers so that procedures can be printed during power outages.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 113 | Not Available or Inconvenient to Obtain |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 123 | Procedure Not Readily Available or Inconvenient to Obtain |