145: Overlap or Gaps Between Procedures
Definition/Typical Issues
Do multiple procedures cover the same task? Are there gaps between procedures that are used in sequence?
Examples
Example 1
- An operator started up the plant air system using the normal procedure. He then discovered a separate procedure specifically for starting up the system. The two procedures had different startup steps. The startup steps in the normal procedure were incorrect. As a result, the plant compressor was damaged.
Example 2
- The operator started the cooling water system using CW-N-01, Normal Cooling Water System Startup. He then began the startup of three feed pumps using procedure FP-N-01, Startup of the Feed System. Gaps existed between these two procedures. Key steps were missing that were supposed to be performed after startup of the cooling water system and before startup of the feed system. As a result, one of the feed pumps was damaged.
Example 3
- A booster pump on a pipeline was not included in the maintenance or operations procedures. The divisions upstream and downstream of the pump each thought the pump was the responsibility of the other division. As a result, the pump failed due to lack of maintenance.
Typical Recommendations
- Develop a procedure development plan to allocate tasks between procedures.
- Review procedures to determine overlaps between them.
- Perform a walkthrough of the procedures to identify overlap or gaps between them.
- 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 |
| 137 | Overlap or Gaps Between Procedures |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 142 | Overlap or Gaps Between Procedures |