142: Facts Wrong, Requirements Incorrect, or Content Not Updated
Definition/Typical Issues
Was specific information in the procedure incorrect? Did the procedure contain out-of-date requirements? Did the procedure fail to reflect the current status of equipment? Were calculations performed incorrectly in the procedure?
Was a typographical error in the procedure responsible for the event?
Was there a failure to incorporate customer requirements into the procedure?
Note 1: Errors in graphics are addressed under the Graphics/Drawing Issue (#136) node.
Examples
Example 1
- A mechanic made a mistake calibrating a level alarm because the procedure specified the wrong limits. As a result, the alarm failed to annunciate during an emergency.
Example 2
- An operator ruined a batch of product when he incorrectly operated the computer control system. New software had been installed, but the procedure had not been updated to be consistent with the new software.
Example 3
- A safety limit was violated because the procedure did not contain the current limits. The limits had been changed, but the master procedure had not been revised.
Example 4
- An operator made a mistake because the procedure contained the wrong limit. The maximum temperature was supposed to be 38°C, but the procedure said 48°C. The mistake was made during typing and not caught by the validators.
Example 5
- An operator overfilled a tank because of a procedure error. The procedure should have stated "Hold the valve open for 3-4 seconds." The typist inadvertently removed the hyphen (when the spell-checker in the word processing software flagged this potential misspelling) and the procedure then read, "Hold the valve open for 34 seconds."
Typical Recommendations
- Have procedures validated by a team of subject matter experts (workers) and by walkthroughs in the field.
- Perform a hazard review of critical procedures to identify errors in procedures.
- Use a word processor to electronically spell-check the procedure immediately after it has been typed.
- Allow a technical editor to review procedures for typographical errors.
- Allow employees to review procedures for accuracy. Solicit feedback from employees.
- Validate new procedures to ensure that they reflect intended practice.
- Instill a practice of identifying errors in procedures; correct errors in a timely manner.
- Provide a method to quickly make clarifications, correct typographical or grammatical errors, or make other adjustments that improve the procedures.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 125 | Data/Computations Wrong/Incomplete |
| 131 | Typographical Error |
| 133 | Facts Wrong/Requirements Not Correct |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 136 | Typographical Error |
| 138 | Facts Wrong/Requirements Incorrect |