144: Missing Steps/Content/Situation Not Covered
Definition/Typical Issues
Were details of the procedure incomplete? Was insufficient detail presented? Did the procedure fail to address all situations likely to occur during the completion of the procedure? Was a critical step missing?
Note 1: This node addresses specific issues that are not included in a procedure. If procedures in general do not have a sufficient level of detail, consider coding under the Too Much/Too Little Detail (#139) node.
Examples
Example 1
- A mechanic did not correctly replace a pump. The instruction stated to "replace the pump." Numerous actions were required to replace the pump, including an electrical lockout, which was incorrectly performed.
Example 2
- A severe decomposition and release of chlorine occurred when the operator failed to check the strength of caustic in the neutralizer. The procedure did not include an instruction for this step, although most experienced operators did perform this check.
Typical Recommendations
- Ensure that all modes of operation, all maintenance activities, and all special activities have written procedures.
- Perform a hazard review of critical procedures to identify missing content in procedures.
- Establish safe operating limits for each process parameter where deviation from the limit is credible and could lead to an unsafe condition. Also, for each safe operating limit, state the potential consequence of exceeding the limits and the steps to avoid deviation or return the process to a safe condition if there is an excursion outside of the safe operating limits.
- Clearly state limiting conditions for each mode of operation (e.g., whether or not to stop processing if certain safety systems are not in service).
- 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 |
| 136 | Incomplete/Situation Not Covered |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 141 | Incomplete/Situation Not Covered |