165: Rule-based Behavior Issue
Definition/Typical Issues
Was the issue caused by blind application of a rule or procedure? Was the issue caused by the inappropriate application of a rule or procedure?
Examples
Example 1
- The alarm limits for cooling water flow were set very close to the normal values. The alarm went off frequently. The operators learned to ignore the alarm because it was part of normal operations. As a result, when cooling water flow stopped because of a failed pump, the operators did not respond.
Example 2
- During an upset condition, the operators misdiagnosed the situation. As a result, they implemented procedure ABN-001 instead of ABN-002.
Example 3
- The procedure for shutting down lines A and B were slightly different. Line B was shut down frequently. Line A was rarely shut down. As a result, when operators shut down line A, they used the procedure for line B. This resulted in dumping 1,000 pounds of product on the floor.
Example 4
- A chemistry technician used the incorrect procedure to process a quality assurance sample. As a result, the sample was found to be acceptable when it was not.
Example 5
- A quality assurance technician used the incorrect procedure to perform an inspection of an electrical component. As a result, the technician shut down a process pump.
Example 6
- A supervisor did not contact the contracts administrator, as he was supposed to, when purchasing some spare parts. Normally, he did not have to work through the contracts administrator to purchase parts. As a result of omitting the step, some mandatory inspection requirements were not included in the contract.
Example 7
- Operators did not perform a lockout/tagout for a simple valve repair. The repair was only going to take about 10 minutes and they had performed this same task numerous times before.
Example 8
- Two temperature indicators displayed different oil temperatures. The operator assumed that the one gauge had failed high and ignored the indication. In fact, the other gauge failed as-is. As a result, the diesel engine sustained severe damage from overheating.
Typical Recommendations
- Avoid situations that appear similar but require different actions to be taken.
- Provide error-proofing to alert operators that their actions are incorrect.
- Ensure that procedures for similar tasks are distinctive.
- Provide information at the point of use that provides the directions/procedure for the task.