141: Wrong Action Sequence/Ordering
Definition/Typical Issues
Were the instructions/steps in the procedure out of sequence? Were the steps out of order?
Examples
Example 1
- An operator made a mistake because the steps were out of sequence in a procedure. Step 5 directed the operator to transfer material from Tank A to Tank B. Step 7 directed the operator to sample the contents of Tank A before transferring.
Example 2
- To isolate a sludge tank, a drain line was supposed to be closed before opening a flush line. However, the procedure had the operator open the flush line first. As a result, a small amount of sludge was sent down the drain line every time the procedure was implemented.
Typical Recommendations
- Have procedures validated by a team of subject matter experts (workers) and by walkthroughs in the field.
- Perform a guide word analysis of procedures to identify out-of-sequence action steps.
- Validate new procedures to ensure that they reflect intended practice.
- Instill a practice of identifying errors in procedures; correct errors in a timely manner.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 132 | Sequence Wrong |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 137 | Wrong Action Sequence |