130: Wrong Revision Used
Definition/Typical Issues
Was an older version of the procedure used? Did the procedure user perform the action as the previous revision specified rather than the current revision?
Examples
Example 1
- An operator liked to use his marked-up version of the procedure because it contained the system operating limits, which were contained in a different document. The operator always checked his personal version for updates, but he missed adding a recent change. As a result, he shut down the process when he performed the procedure incorrectly.
Example 2
- Revision 6 of a procedure was used instead of the current Revision 7. The operator had printed out the procedure when she was about to begin the work 2 weeks ago. When the task was delayed, she set the procedure aside. When the task came up on the schedule again, she just grabbed the old procedure from 2 weeks earlier.
Example 3
- Maintenance personnel often made printouts of procedures that they kept at their workstations. That way they did not need to get a new copy of the procedure each time. However, they did not check for updates each time before use. As a result, some procedure steps were missed.
Typical Recommendations
- Ensure that only current copies of procedures are available.
- Seek out and destroy old versions of procedures.
- Consider incorporating information added by operators to their "personal" copies of procedures.
- Provide a means to ensure that previous versions of procedures are not available or used.
- Conduct a "tool box" audit to ensure that personal copies of outdated, marked-up copies of procedures are not used by workers in the field.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 134 | Wrong Revision or Expired Procedure Revision Used |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 139 | Obsolete Version Used |