136: Graphics/Drawing Issue
Definition/Typical Issues
Was an error made because graphics or drawings were of poor quality? Were the graphics or drawings unclear, confusing, or misleading? Were graphics, including data sheets, illegible? Would a graphic (diagram, picture, chart, etc.) have significantly reduced the likelihood of this error?
Examples
Example 1
- A mechanic replaced the wrong seal on a large piece of equipment. The pump subsequently failed prematurely. The seal that he was to remove was shaded on the drawing, but he could not determine which seal was shaded because the copy was of poor quality.
Example 2
- An electrician incorrectly terminated a wire. This resulted in problems restarting the system. The wire terminations were shown on the installation diagram. The procedure copy he was using was not legible because it was made from a copy of a copy of the original.
Example 3
- An operator opened two valves in the wrong sequence during a complex procedure to backwash an enclosed rotary filter containing highly reactive peroxides. A diagram of the filter (showing equipment labels) and proper labeling of the filter valving would have greatly clarified the procedure.
Example 4
- An operator made an error in determining whether the reactor's temperature and pressure were acceptable. The acceptable temperature was dependent on the pressure. The operator had a long set of look-up tables that listed the acceptable temperature for each pressure. A pressure-temperature graph indicating acceptable and unacceptable regions would have reduced errors.
Typical Recommendations
- For hard-copy graphics that have been reproduced, ensure that the copy is easy to read (e.g., not too dark, too light, or splotchy).
- Include color-coding on graphics when possible for easy use.
- Ensure that the graphics accurately depict actual process operations and/or equipment configuration.
- Do not overwhelm the user with too many graphics on one screen or one sheet of paper. Information should not appear crowded.
- The text should support the graphics.
- Flowcharts should be used to support decision making and branching processes.
- Include pictures and diagrams where appropriate.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 123 | Graphics LTA |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 130 | Graphics/Drawing Issue |