129: Procedure Difficult to Identify
Definition/Typical Issues
Is it difficult to identify the correct procedure to use? Do many procedures have similar names? Was there a failure to clearly distinguish procedures for different units from one another?
Examples
Example 1
- An operator used the wrong procedure to start up compressor 3B. Originally, there was one compressor installed, designated as Compressor 3. During modifications to the plant, Compressor 3 was replaced with two compressors of a different type, designated as Compressor 3A and Compressor 3B. However, the procedure for Compressor 3 was still available even though that particular compressor had been removed years earlier. When the operator needed to start up Compressor 3B, he saw the procedure labeled "Compressor 3 Startup" and assumed that it applied to 3A and 3B. The correct procedure, "Startup of Compressors 3A and 3B," was much farther down the alphabetical list of procedures.
Example 2
- A mechanic incorrectly calibrated a pressure transmitter. A page from a similar procedure was inadvertently substituted into his calibration procedure. Individual procedure pages did not contain procedure titles or procedure numbers, so the substituted page was difficult to distinguish from the others.
Typical Recommendations
- Include a header at the top of each procedure page that includes the procedure number, page number, procedure revision, and unit number.
- Use different-colored paper for each unit's procedures (i.e., blue for Unit 1, pink for Unit 2).
- Provide clear, descriptive names for each procedure.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 129 | Difficult to Identify |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 134 | Procedure Difficult to Identify |