143: Inconsistent Procedural Requirements
Definition/Typical Issues
Did different procedures related to the same task contain different requirements? Were there conflicting or inconsistent requirements stated in different steps of the same procedure? Were requirements stated in different units (i.e., gallons versus liters, meters versus feet)?
Examples
Example 1
- An operator exceeded the environmental discharge limits. A caution in the procedure stated the flow rate limit in pounds per hour of material. The procedure step stated the limit in gallons per minute. The operator set the flow rate based on the gallons per minute limit, which was less restrictive in this case.
Example 2
- The procedure said to send the completed form to the PSM Coordinator, but the form itself had a note on the bottom that said to send it to the operations manager. As a result, the form was misrouted.
Example 3
- A caution of the cover of a detector stated: "The cover of this detector should not be opened until power is disconnected." But Step 9 of the procedure said, "After removing the cover, disconnect power to the detector and push the red button to discharge the capacitor." As a result, the technician received an electrical shock.
Typical Recommendations
- Have procedures validated by a team of subject matter experts (workers) and by walkthroughs in the field.
- Develop a system for personnel to report procedure issues.
- 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 |
| 135 | Inconsistency Between Requirements |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 140 | Inconsistency Between Requirements |