131: Correct Procedure Used Incorrectly
Definition/Typical Issues
Was an incident caused by an error made while following or trying to follow a procedure? Was the format laid out in the wrong format? Was the procedure misleading or confusing? Was there more than one action per step? Were the procedure graphics inappropriate? Were there language or wording issues that made the procedure difficult to use? Was the procedure too detailed? Was the procedure not detailed enough?
Note 1: This node addresses the incorrect use of the appropriate procedure. Use of the wrong procedure is addressed under the Correct Procedure Not Used (#123) node.
Examples
Example 1
- An operator incorrectly completed a step of a procedure requiring him to open six valves. He skipped one of the valves.
Example 2
- An operator was calculating the catalyst required for a batch of material. He used the chart incorrectly and added the wrong amount of catalyst.
Typical Recommendations
- Ensure that procedures are in a standard, easy-to-read format.
- Ensure that procedures use the appropriate level of detail for the complexity and frequency of a task.
- Use look-up tables instead of requiring calculations to be performed.
- Use specific component identifiers.
- Monitor incident reports for evidence of deviation from established procedures.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 117 | Misleading/Confusing |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 125 | Misleading/Confusing |